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The War on Cancer

The War on Cancer
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A couple of weeks ago Tim Ferriss and I were having dinner and the topic of cancer came up. As some of you may know my background is in oncology, specifically in exploring immune-based therapies for cancer by exploiting the properties of regulator T-cells.  But that was a long time ago.  Like many of you, I expect, I’ve also been personally impacted by cancer having lost a friend to glioblastoma multiforme (GBM). I often describe GBM to people as one of the cancers that gives cancer a bad name.  When I went to medical school I planned on becoming a pediatric oncologist, and though I ultimately chose to pursue surgical oncology, my interest in helping people with cancer never wavered.

Over dinner that night, Tim asked me if I could write – in about 1,000 words! – a post on cancer that would be interesting and digestible to a broad audience.  “1,000 words?!,” I asked. “How about 30,000 words?,” I responded only half kidding. After explaining why I couldn’t possibly write such an abridged version, Tim talked me into it. And so, I plan to accept the challenge and hope to provide readers with such a post (it will be on Tim’s blog when I do so), hopefully in the next month or two.

For an introduction, however, I’d like take a step back and place this topic in a broader context. I don’t need to say much about cancer that you don’t already know.  You probably know that about one in three Americans will develop cancer in their lifetime, and you probably know that about half of them will succumb to the disease.  What you may not know, however, is that we have made virtually no progress in extending survival for patients with metastatic solid organ tumors since the “War on Cancer” was declared over 40 years ago.  In other words, when a solid organ tumor (e.g., breast, colon, pancreatic) spreads to distant sites, the likelihood of surviving today is about what it was 40 years ago with rare exceptions. We may extend survival by a few months, but not long-term (i.e., overall) survival.

We screen better today for sure, but subtracting lead-time bias, it’s not clear this extends overall survival.  We’ve had success in treating and even curing hematologic cancers (e.g., some forms of leukemia and lymphoma).  Certainly testicular cancer patients (especially seminomatous) are better off today and those with GI stromal tumors (GIST), too.  Surgical control of cancer is much better today and some local treatments (e.g., specific radiation), too.  But for the most part, when a patient has metastatic cancer today, the likelihood of living 10 more years is virtually unchanged from 40 years ago.

About a year ago, I was asked to give a talk about metabolic disease to a group of physicians. But before I spoke, a very astute and soft-spoken oncologist, Dr. Gary Abrass, gave the following introduction as a way to frame the context of my talk.  After all, I’m sure many in the audience were wondering what could a discussion of insulin resistance have to do with cancer. I have thought often of his words that night in the many months since he so eloquently and informally introduced me.

I asked Dr. Abrass if I could have a copy of his talk and share it with you, to which he kindly agreed. Below is, nearly verbatim, the talk he delivered that night.  (Dr. Abrass did give me the liberty of tweaking the text a bit, for emphasis and clarity.)

How have we fared in the War on Cancer?

On December 23, 1971, President Nixon declared war on cancer by signing the National Cancer Act. I was going to title this, “40 years in 4 minutes,” but I think this will take me a bit longer. At the time I was a third year medical student.  Two years before, Neil Armstrong had inflated our national pride by setting foot on the moon, and there seemed no scientific goal unachievable. Activist Mary Lasker published a full-page advertisement in The New York Times: “Mr. Nixon: You Can Cure Cancer.” And she went on to quote Dr. Sidney Farber, Past President of the American Cancer Society and whose name now sits atop the Harvard Cancer Center, “We are so close to a cure for cancer. We lack only the will and the kind of money and comprehensive planning that went into putting a man on the moon.”  Since then, the federal government has spent well over $105 billion on the effort.

Forty years later, Dr. Farber’s prophecy remains unfulfilled.  In 2012 cancer killed an estimated 577,190 people in the United States.  The death rate, adjusted for the size and age of the population, has decreased by only 5 percent since 1950.  And most of this decline is due to mammography screening in breast cancer and cessation of smoking, resulting in less lung cancer in men.

We have however developed a greater understanding of the biological and molecular basis of cancer.  When I was a medical student, this graphic summarized what we knew about the growth cycle of the cancer cell.

cell cycle

There was an S-phase in which DNA was synthesized, a mitotic phase when the cell divided and a G1 and G2, which to my mind stood for “gaps” in our knowledge.  We added a few dozen chemotherapy drugs on this wheel, and treatment basically amounted to carpet-bombing. And for some diseases — particularly leukemias, lymphomas, and testicular cancers — it was quite effective.

The next graphic demonstrates what we have learned, a truly overwhelming accomplishment, a dizzying array of interconnecting signaling “pathways,” and spawned a whole new field, “translational medicine.”

Signal_transduction_pathways

Receptors have been identified on the surface of cells, which function as locks to be opened by various circulating substances (i.e., hormones) initiating a series of downstream events. Mutations in this cascade of on/off switches can promote tumor growth.

With the completion of the Human Genome Project, new sequencing technologies have also opened up the prospect of personal genome sequencing as an important diagnostic tool. A major step toward that goal was the completion of the sequencing of the full genome, first on James D. Watson, one of the co-discoverers of the structure of DNA.  In fact, Steve Jobs had personal genome sequencing.  The price is down to $1,000 and Mayo Clinic Proceedings recently had an article raising the concern of direct to consumer advertising for genomic sequencing. We are now able to sequence gene by gene, pathway by pathway, the genetic code of some cancers.  New “smart” drugs have been developed that target various mutations in these pathways. And currently there are over 800 “targeted agents” in clinical development.  These drugs have been described by some investigators as “The Holy Grail,” but the clinical results suggest more of a commemorative cup for a “Happy Meal.”

While there is nothing unique about this paper, it is a good example of a typical negative trial targeting the IGF-1 receptor with a monoclonal antibody.  The lack of response does not make us question the role of the IGF pathway as a prime driver of malignancy, but rather demonstrates the ability of the cancer to resist therapy.  It seems there is so much redundancy in the system that the cancer finds alternate pathways. The cancer cell continues to defend itself, to bob-and-weave like the arcade game “Whack-a-Mole.”

So the investigators combined the IGF-1 monoclonal antibody with various other therapies: standard platinum based chemotherapy regimens, the “small molecule” tyrosine kinase inhibitor gefitinib (Iressa) targeting another common pathway (EGFR), and also the mTOR inhibitor temsirolimus (Torisel) which targets the IGF-1 pathway a bit further along.  In any case, the point is, it still didn’t work. But why?

Investigators have mapped the genome of a typical lung cancer patient and found over 50,000 mutations. That’s a lot of targets! Granted they are not all ‘driver’ mutations, some are ‘passenger’ mutations. The patient whose genome was mapped was a 51-year-old man who’d reported smoking 25 cigarettes a day for 15 years. At 50,000 mutations, it works out to one mutation for every 2.7 cigarettes.

Last year the New England Journal of Medicine published a study by Gerlinger and colleagues. These investigators looked at intra-tumor heterogeneity. They performed a molecular dissection. They found diversity within the tumor itself.  Each cancer is not cancer but, indeed, it is CANCERS. In other words “all cancers are rare cancers.”  Let me repeat this point.  Each tumor is a collection of heterogeneous – not homogenous – mutated cells. This article has engendered some discussion and some controversy. Many say that the results of the study bring the idea of personalized medicine to a halt, or at least dramatically slow it down.  Are there exceptions? Yes, but they are rare.  One example of an exception to this revelation is chronic myelogenous leukemia (CML), a cancer with a known single driver mutation.

In September 2011, biologist Dr. Alasdair MacKenzie of the University of Aberdeen, speaking at the British Science Festival in Bradford, explained that researchers trying to fully understand how our DNA causes disease might not be looking in all the right parts of the genome. The past decade of genetic studies has revealed that our 3.2-billion-long-DNA-letter code is more complex than anyone could have thought.  More than 98% of the human genome does not encode protein sequences. It’s been referred to as “Junk DNA” and thought not to have a function, but maybe more correctly is that we do not know the function.  He refers to this as the “dark matter” of the genome. And it’s thought that some of these “alternate pathways”, in which our resourceful cancer cell seeks refuge, may reside here. If this was not complicated enough, the new field of Epigenetics has grown exponentially resulting in a widening of the battlefield.

These are factors that can affect the expression of genes without causing mutations, turning switches on and off.  In terms of cancer, much of this research has concentrated on what are called “Nononcogenic stress targets.”  We can stress an organism in many ways: heat, poison, starvation, suffocation or more scientifically thermal, chemical, metabolic and oxidative stress.  Organisms have an ingenious way of responding to such stress.  In the 1960s an assistant in FM Ritossa’s lab accidentally boosted the incubation temperature of Drosophila (fruit flies), and when later examining the chromosomes, Ritossa found a “puffing pattern” that indicated the elevated gene transcription of an unknown protein.

This was later described as the “Heat Shock Response” and the proteins were termed the “Heat Shock Proteins.” This same HSP increases survival under a great many pathophysiological conditions. The HSP70s are an important part of the cell’s machinery for protein folding and help to protect cells from stress. While it enhances the organism’s survival and longevity under most circumstances, HSF1 has the opposite effect in supporting the lethal phenomenon of cancer. These proteins enhance the growth of cancer cells and protect tumors from treatments. This remarkable protein affords a protective response to other proteins in the cell, acting as a “chaperone” preventing them from mis-folding or “denaturing,” like when a boiled egg white turns opaque. These heat shock proteins are expressed at high levels in many tumor types: breast, endometrial, lung, prostate, even brain tumors. HSP overexpression signals a poor prognosis in terms of survival and response to therapy. HSP’s are now on the radar as a key target in the ongoing battle. This protein folding stress response is a hot topic in current cancer research.  I have been communicating with Dr. Debu Tripathy who is currently studying epigenetic changes and protein folding stress responses associated with obesity. This protein folding stress response affords the cancer cell a survival advantage, and we share this protective mechanism with a fly, such a distant relative in our family tree, that one can only conclude that the cancer cell has hijacked this maneuver, this protective drive for immortality from the legacy of 100’s of millions of years of evolution…such a resourceful and formidable opponent.

In any case, when the Human Genome Project was near completion, President Clinton hosted a White House ceremony and announced that, “it will revolutionize the diagnosis, prevention and treatment of most, if not all, human diseases, and that humankind is on the verge of gaining immense new power to heal.”

The hubris of it all.  It’s reminiscent of the quote of Sidney Farber.  Hopefully this is not tempting fate.  Theologians tell us the only unforgivable sin is pride. The increasing complexity of the science is affording us quite a dose of humility.  British Physicist Brian Cox said that “being at the junction of the known and the unknown is a beautiful place to be for a scientist,” but it seems the more we know, the more we don’t know.  Not unlike Winston Churchill’s characterization of Russia as “a riddle wrapped in a mystery inside an enigma.”  Not unlike modern theoretical physics, one questions whether we are capable of understanding the complexity of the science.  Hopefully it’s not like trying to teach my dog quantum theory. We are so smart, but it seems that the cancer cell is smarter. It bobs and weaves, slips our punches, and when we back it into a corner, it defends itself in remarkable ways borne of millions of years of evolutionary acumen much of it hidden in the dark matter of our genome.

Maybe we should call a truce in the War on Cancer and concentrate on prevention. Besides smoking, the most preventable cause of cancer seems to be obesity.  It is generally thought that obesity may account for about a third of many cancer types, particularly breast, colon, uterus, kidney and esophagus.  Obesity is a risk factor for type II diabetes and these patients are not only more likely to get cancer, but to have poor outcomes. Other speakers will explore the relationship of obesity and cancer, the epidemiology and the science, and see if this lends support to any practical prevention measures.

Gary Abrass, M.D.
April 19, 2012

Afterword

Just as the best way to get in shape is not to ever get out of shape, the best treatment for cancer is almost assuredly not to get cancer. And that’s clearly the theme of the introduction Dr. Abrass gave me.  But I’m sure many of you are asking a more important question — what happens if I or someone I care about has cancer? If you can be patient with me, I do plan to address this, to the best of my understanding, in the coming months.

 

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About the Author:

Peter Attia, M.D., is the co-founder and President of the Nutrition Science Initiative (NuSI), a non-profit based in San Diego, CA. He received his B.Sc. from Queen's University in Canada and his M.D. from Stanford Medical School in California. After his surgical residency in general surgery at Johns Hopkins he worked as a consultant at McKinsey & Company. He founded NuSI with scientific journalist Gary Taubes in 2012.

Discussion

  1. Matt  October 8, 2013

    I keep meaning to pick up George Johnson’s new book The Cancer Chronicles. Have you taken a look at it or heard through your sources whether or not it is good?

    (reply)
  2. Ryon Graf  October 8, 2013

    Thanks for touching upon this.

    Just a few weeks ago Nature produced an issue with several review articles discussing the state of our knowledge on intratumor heterogeneity: http://www.nature.com/nature/journal/v501/n7467/full/nature12627.html

    Although there are instances in which the sheer number of mutations are overwhelming (lung cancer and melanoma being the worst) there are instances of very good (at least initial) responses to targeted therapy even with highly mutated systemic cancer. An example is vemurafenib, which targets the Braf V600E mutation in ~50% of surveyed melanoma biopsies in the TCGA dataset. Recent work by Rene Bernards and others are identifying common evolutionarily favored “escape” pathways for resistance to these drivers (http://ryongraf.com/2013/09/usha-mahajani/) that are actionable with current therapeutics. It’s not a cure, but it is progress.

    Along the lines of non-ncogenic stress targets, a recent Phase I clinical trial was conducted using a ketogenic diet as an intervention in metastatic, heavily pre-treated cancer patients: http://www.ncbi.nlm.nih.gov/pubmed/21794124 Overall, the results are favorable for a Phase I study.

    All that said, as someone actively involved in research on cancer metastasis, I acknowledge the immense challenge of treating systemic cancer in any capacity, and I am immensely interested in any measure that can be used to prevent cancer. However, the clinical trial design to test and validate prevention interventions is very difficult, but that not an excuse, and is perhaps a discussion for another time!

    Ryon

    (reply)
    • Peter Attia  October 8, 2013

      Ryon, thanks so much for putting additional perspective on this. I could not agree with you more that primary prevention trials will be very difficult, and money would probably be better spent at secondary prevention (i.e., adjuvant setting, but not neoadjuvant setting). I spent too much time thinking about this and discussing it others, but the right trial is still a few clock cycles away from me. I will dive into this more in subsequent posts.

      p.s. Andrew and I missed you on Fiesta this morning for some FTP sets…next time?

  3. Ash Simmonds  October 8, 2013

    “…a 51-year-old man who’d reported smoking 25 cigarettes a day for 15 years…”

    Wait – who starts smoking at age 36?

    (reply)
    • wukang  October 8, 2013

      He might start smoking much earlier than 36, but not at the rate of 25 cigarettes per day

  4. Kathy  October 8, 2013

    Thank you for all you do, Peter. I love the conclusion of this article — “Maybe we should call a truce in the War on Cancer and concentrate on prevention. Besides smoking, the most preventable cause of cancer seems to be obesity.” The challenge being that we haven’t found an answer to help people with sustainable weight loss, as witnessed by the diet industry being a $2 Billion industry. What would it take for this to change? In my opinion it is to address improvements to a person’s state of health not only in terms of the physical aspects of diet and exercise, but to take a more holistic approach and delve into a person’s well-being on a mental, emotional and even spiritual level. What is driving a person to over consume foods (oftentimes less than healthy foods) rather than nourish their bodies? I’d encourage anyone reading this to find a program like we’ve developed that provides a simple and very sustainable approach to making true lifestyle changes in a way that becomes natural to them and part of a lifelong dedication to being the best they can be. In the first week of making wiser eating choices people in our program are enjoying losing weight, feeling less joint pain, sleeping better, feeling energized throughout the day and just are happier. That’s the outer, and we know that these eating choices are reversing the metabolic syndrome and insulin resistance — after 7 short days! The essential piece to sustained results, however, isn’t about adhering to some eating program, it is coaching that helps people uncover what they are stuffing emotionally or what is seeking to be expressed creatively through them… they make the connection and what once required “motivation” is now sustained through true “inspiration”. The statistic is that upwards of 90% of today’s chronic conditions can be positively impacted by better lifestyle choices. I’d invite anyone to take a 6-week journey of self-discovery to improve their health in a way that may very well improve conditions they might be facing. Be Well!

    (reply)
    • Peter Attia  October 8, 2013

      Kathy, to my last check the diet industry may be closer to $40 billion! But that only makes your point more pronounced. I have very strong views on why this is the case: http://eatingacademy.com/nutrition/two-choices

    • Marcia  October 9, 2013

      Kathy – do you have a link to a website that incorporates your suggestions? Just curious.

  5. mike  October 8, 2013

    Have you read Cancer as a Metabolic disease?

    (reply)
    • Peter Attia  October 8, 2013

      By Tom Seyfried? If that version, yes. Excellent resource. Subsequent post(s) will get to these ideas. I am in the Seyfried “camp” if you will.

    • mike  October 8, 2013

      Yes, by Tom Seyfried. I’m totally onboard with that line of thought. Would love to hear your input on the topic.

    • Peter Attia  October 9, 2013

      In time…

    • neilfeldman  October 9, 2013

      Peter,

      I am deep inside the camp of Dr. Seyfried as well. However, when you do take up the topic, I hope you will address the implications of this paper:

      http://www.cancerandmetabolism.com/content/1/1/5

      In particular, the effect that limiting blood glucose levels (through a ketonic diet) might have on preventing T cells from becoming fully activated.

    • Peter Attia  October 9, 2013

      Interesting study. Not sure of the implications, though.

    • Herb  October 9, 2013

      Dr Nicholas Gonzalez – who cured me of metastatic cancer to the liver 25 years ago and who remains my physician has written an 8 part critique of Tom Seyfried’s work. See http://www.naturalhealth365.com/ketogenic_diet.

      I would urge – if not plead with you Peter to look at Dr Gonzalez’s model of cancer causation and treatment.

      It’s enormously controversial, and remarkably – even miraculously – effective in treating advanced cancer.

      See more at dr.gonzalez.com

    • Peter Attia  October 9, 2013

      Will do.

  6. J  October 8, 2013

    This is a fantastic post. I do not think people realize that cancer really is CANCERS. Lung cancer in one patient is not the same as lung cancer in another. There may be over 100 unique mutations in each case. They cannot be treated the same and if they are, the outcome will be different. Every tumor is unique. Every metastasized tumor is not the same either. When people get frustrated at the lack of advancement, I do not believe they realize just how complex it really is. I hope numerous people read this and begin to understand the magnitude of it. There is hope though, it is just a matter of time

    (reply)
    • Peter Attia  October 8, 2013

      Yes, no reason to give up hope just yet.

  7. Duke  October 8, 2013

    I’ve been following your interesting experiment with ketosis and diet. Just an average joe interested in nutrition.
    I assume you aren’t sold on the PCRM storyline that says that Plant Based Diet is a great way to help avoid cancer.
    Higher protein intake promotes some types of cancer growth?
    NutritionFacts.org among others really promote plant based as a way to hopefully avoid cancer.
    Any thoughts?

    (reply)
    • Peter Attia  October 8, 2013

      Correct, Duke. I’m certainly familiar with the arguments for this approach, but I have never seen compelling evidence, at least compelling enough to change my behavior. The problem is two-fold: i) Ecologic studies offer no evidence (despite a compelling narrative), ii) the animal and cell experiments are highly flawed (e.g., dose, cell line, protein type).

      So until I see compelling evidence, I will continue to eat as I do.

  8. steve  October 8, 2013

    Look forward to your analysis and views. My little understanding of the subject is that only tissue that proliferate vs. those that may not, or not nearly as much are susceptible to mutation. Somehow, the the status of the oncogene and tumor suppressing factor is altered. Cancer like CAD is age driven so anything that might accelerate the aging process and early ignition of the cancer process needs to be forestalled. Very possible IR a contributing factor.
    I also understand that those with allergies seem to incur cancer at much lower rate due to an overactive immune system which in this case might be good, but in other instances not so good.
    Again, look forward to your thoughts.

    (reply)
  9. caroline  October 8, 2013

    THANKS FOR ALL YOU DO!!!
    LOOKING FORWARD TO THE 1000 WORD POST!!!
    THAT MUST HAVE BEEN A FUN DINNER.

    (reply)
    • Peter Attia  October 8, 2013

      Caroline, they always are!

  10. tex8ranch  October 8, 2013

    I am a 3x breast cancer survivor and am in the ketogenic camp ….. I look forward to your commentary!!

    (reply)
  11. Mike  October 8, 2013

    I’ll be interested to see your write-up…with your oncology background and work with NuSI, I suspect your viewpoint may be somewhat different from many in the cancer research community. I assume you’re familiar with Seyfried’s work framing cancer as a metabolic disease.

    http://www.ncbi.nlm.nih.gov/pubmed/20181022
    http://www.amazon.com/Cancer-Metabolic-Disease-Management-Prevention/dp/0470584920

    And a long but interesting (to me, as a layperson) synopsis of the history of cancer research that mentions Seyfried’s work, as well:

    http://robbwolf.com/2013/09/19/origin-cancer/

    (reply)
    • Mike  October 8, 2013

      And I see that others were faster than I — looks as if this has already been mentioned!

    • Peter Attia  October 8, 2013

      Yes, yes, and yes…

    • Richie Graham  January 14, 2014

      That Robb Wolf article is fascinating. I had already bought and read part of Seyfried’s book Cancer as a Metabolic Disease, after seeing a YouTube video of him. This article makes me want to go home and read the rest of the book immediately. Thanks for posting. I look forward to Peter’s coming take on this topic.

  12. Alexandra M  October 8, 2013

    Is that the Tim Ferriss of “The 4 Hour Work Week” and other extreme self-help books (not Timothy Ferris, author of Coming of Age in the Milky Way)? I trust your judgement, but I’d be a little concerned that your appearing in his blog would look better on his CV than it would on yours. :(

    Do you really believe his claim that the supplement he developed (Brain Quicken) would dramatically increase short term memory within 60 minutes?

    (reply)
    • Peter Attia  October 8, 2013

      I’m friends with Tim Ferriss, and do not know Timothy Ferris.

    • Alexandra M  October 9, 2013

      I’m disappointed that you didn’t answer my question about his supplements.

      As you know, I’ve been a follower of your blog, and a supporter of NuSci.

    • Peter Attia  October 9, 2013

      Alexandra, I have no idea what you’re talking about. Sorry.

    • Curtis  October 9, 2013

      I agree with Alexandra. When I read “Tim Ferriss and I were having dinner” a wave of disappointment came over me. Never met him, so will do my best to reserve judgement, but seriously?

    • Peter Attia  October 9, 2013

      Curtis, I think your latter instincts are correct. Do your best to reserve judgment.

  13. Mark B  October 8, 2013

    Thanks for the article. I have something of an interest in this area since my uncle died from cancer and my sister-in-law is a breast cancer survivor. There is a very interesting article posted on Robb Wolf’s blog relating to cancer. It is by Travis M Christofferson. Here is the link: http://robbwolf.com/2013/09/19/origin-cancer/. The main context of the article is sugar’s role in cancer. He also touches on some of the points mentioned here.

    (reply)
    • Peter Attia  October 8, 2013

      Yes, I read the earlier (much more detailed, much longer) version of Travis’ piece a few months ago when he shared it with a friend and gave that friend permission to share with me.

  14. Tim  October 8, 2013

    Look forward to the bigger post. Would love to hear what you think about Cancer as a metabolic disease. Here is a talk regarding this subject by Thomas Seyfried:
    http://www.youtube.com/watch?v=sBjnWfT8HbQ&noredirect=1

    Review of Seyfried’s book (part 1)
    http://diagnosisdiet.com/what-causes-cancer/

    (reply)
    • Peter Attia  October 8, 2013

      See response to previous comment. I share this view of cancer.

  15. Rick Donnelly  October 8, 2013

    I’ve lost more than my share of close friends and loved ones to cancer. The only one who beat the odds in a big way was the one who zealously followed the so-called Pauling protocol (megadoses of vitamin C and certain amino acids). He may be the far outlier that his oncologist claimed he was, but it has always made me wonder why, after 40 years of zero progress in long-term survival of metastatic tumors, the leading researchers have not questioned their understanding of the underlying pathogenesis? I sincerely hope you represent the leading edge of effective new thinking about this, and anxiously await reading your posts on this. I sincerely hope that you write more than just a single blog entry for Tim.

    (reply)
    • Peter Attia  October 8, 2013

      I will, Rick. But I’m sure not fast enough.

  16. Greg Luke  October 8, 2013

    Hello Dr Attia, I love your blog and site NuSI. I see others have posted ab out Thomas Seyfried, there is also Dr Dr. Dominic D’Agostino and Dr Peter Pendersen who both are working on cancer from a metabolic stand point. One very promising development is 3-BP (3-Bromopyruvate) that Dr Penersen is one of the researchers of. There is also PD-1 that is working with the immune system. Here is a cut and paste from a biochemist friend of mine had posted ” To find a tumor-generated protein that inactivates T-cells was monumental. And it was only a matter of time before scientists countered with an antibody to prevent that protein from binding to PD-1. That has been done, and in a human clinical trial, it worked”.

    REFERENCE: http://www.nejm.org/doi/full/10.1056/NEJMoa1200690

    (reply)
    • Peter Attia  October 8, 2013

      Greg, Dom and I are good friends and are collaborating on several projects. Lots of interesting stuff going on.

  17. Darin  October 9, 2013

    Excellent blog! It is great reading “out of the box” thinking on these important topics. Do you know who I could contact about detecting and tracking algorithms that may be applicable to finding cancers? I have a new algorithm that we think shows potential in this area.

    (reply)
  18. Justin W.  October 9, 2013

    Peter, Thank you so much for this post. I’ve been waiting for you to turn your attention to cancer since I started following you this past spring. I’m the father of a 6 year old boy with a mixed-grade glioma and also the co-founder of a childhood cancer nonprofit (www.maxloveproject.com) that focuses on improving nutrition for families in treatment and survivorship. Your TED Talk and blogging pushed us to take a deeper look at the keto/cancer research and eventually to help interested families find experienced ketogenic dietitians. Because of recent unfavorable MRI scans, we’ve put our son on the KD and we’ve gone with him. Although there are many amazing people doing work in this area, your writing has had a big impact on us and many of the families that we work with (in fact, I wrote a short blog post last week about your impact: http://maxloveproject.org/blog/2013/9/27/maxlove-project-gets-personal-pt-3.) I write this all in order to say thank you! Keep doing what you’re doing!

    (reply)
    • Peter Attia  October 9, 2013

      Justin, I’m sorry to hear about what your little boy is going through. I can’t even imagine. I wish you all the best and I’m sorry we don’t have definitive answers to what to do.

  19. Acme  October 9, 2013

    Peter, do you heard about kataegis e.g. hypermutation in somatic cells, like cancer cells (http://en.wikipedia.org/wiki/Kataegis), which could explain amount of mutation found in cancers. Maybe inhibitor for APOBEC class protein, which drive kataegis, in combination of chemotherapy could improve efficiency of chemotherapy it self, because maybe cancer cells couldn’t get resistance to chemotherapy so fast. Also in theory, these class of inhibitors shouldn’t so toxic to patient .

    (reply)
    • Peter Attia  October 9, 2013

      I’m not familiar with this.

  20. denny  October 9, 2013

    Peter, many thanks for all you do.

    While reading your latest post, the library called to say Dr. Seyfried’s book was in. Thank you, Inter-Library Loan.

    Chapter 19, page 375 offers this: “In principle, there are few chronic diseases that are more easily preventable than cancer.”

    Too bad Mom, Dad, and numerous (female) cousins didn’t get this memo before they expired.

    Several other cousins and I have faired better, if you don’t mind losing a prostate, testicle, breast or cervix along the way.

    http://www.amazon.com/Cancer-Metabolic-Disease-Management-Prevention/dp/0470584920

    (reply)
    • Peter Attia  October 9, 2013

      Very sorry to hear that, Denny. Hopefully we can do better.

  21. Dominic Le Prevost  October 9, 2013

    Have you come across this before?

    Cancer-specific Cytotoxicity of Cannabinoids

    By Dennis Hill

    First let’s look at what keeps cancer cells alive, then we will come back and examine how the cannabinoids CBD (cannabidiol) and THC (tetrahydrocannabinol) unravels cancer’s aliveness.

    In every cell there is a family of interconvertible sphingolipids that specifically manage the life and death of that cell. This profile of factors is called the “Sphingolipid Rheostat.” If ceramide (a signaling metabolite of sphingosine-1-phosphate) is high, then cell death (apoptosis) is imminent. If ceramide is low, the cell will be strong in its vitality.

    Very simply, when THC connects to the CB1 or CB2 cannabinoid receptor site on the cancer cell, it causes an increase in ceramide synthesis which drives cell death. A normal healthy cell does not produce ceramide in the presence of THC, thus is not affected by the cannabinoid.

    The cancer cell dies, not because of cytotoxic chemicals, but because of a tiny little shift in the mitochondria. Within most cells there is a cell nucleus, numerous mitochondria (hundreds to thousands), and various other organelles in the cytoplasm. The purpose of the mitochondria is to produce energy (ATP) for cell use. As ceramide starts to accumulate, turning up the Sphingolipid Rheostat, it increases the mitochondrial membrane pore permeability to cytochrome c, a critical protein in energy synthesis. Cytochrome c is pushed out of the mitochondria, killing the source of energy for the cell.

    Ceramide also causes genotoxic stress in the cancer cell nucleus generating a protein called p53, whose job it is to disrupt calcium metabolism in the mitochondria. If this weren’t enough, ceramide disrupts the cellular lysosome, the cell’s digestive system that provides nutrients for all cell functions. Ceramide, and other sphingolipids, actively inhibit pro-survival pathways in the cell leaving no possibility at all of cancer cell survival.

    The key to this process is the accumulation of ceramide in the system. This means taking therapeutic amounts of cannabinoid extract, steadily, over a period of time, keeping metabolic pressure on this cancer cell death pathway.

    How did this pathway come to be? Why is it that the body can take a simple plant enzyme and use it for healing in many different physiological systems? This endocannabinoid system exists in all animal life, just waiting for it’s matched exocannabinoid activator.

    This is interesting. Our own endocannabinoid system covers all cells and nerves; it is the messenger of information flowing between our immune system and the central nervous system (CNS). It is responsible for neuroprotection, and micro-manages the immune system. This is the primary control system that maintains homeostasis; our well being.

    Just out of curiosity, how does the work get done at the cellular level, and where does the body make the endocannabinoids? Here we see that endocannabinoids have their origin in nerve cells right at the synapse. When the body is compromised through illness or injury it calls insistently to the endocannabinoid system and directs the immune system to bring healing. If these homeostatic systems are weakened, it should be no surprise that exocannabinoids perform the same function. It helps the body in the most natural way possible.

    To see how this works we visualize the cannabinoid as a three dimensional molecule, where one part of the molecule is configured to fit the nerve or immune cell receptor site just like a key in a lock. There are at least two types of cannabinoid receptor sites, CB1 (CNS) and CB2 (immune). In general CB1 activates the CNS messaging system, and CB2 activates the immune system, but it’s much more complex than this. Both THC and anandamide activate both receptor sites. Other cannabinoids activate one or the other receptor sites.Among the strains of Cannabis, C. sativa tends toward the CB1 receptor, and C. indica tends toward CB2. So sativa is more neuroactive, and indica is more immunoactive. Another factor here is that sativa is dominated by THC cannabinoids, and indica is predominately CBD (cannabidiol).

    It is known that THC and CBD are biomimetic to anandamide, that is, the body can use both interchangeably. Thus, when stress, injury, or illness demand more from endogenous anandamide than can be produced by the body, its mimetic exocannabinoids are activated. If the stress is transitory, then the treatment can be transitory. If the demand is sustained, such as in cancer, then treatment needs to provide sustained pressure of the modulating agent on the homeostatic systems.

    Typically CBD gravitates to the densely packed CB2 receptors in the spleen, home to the body’s immune system. From there, immune cells seek out and destroy cancer cells. Interestingly, it has been shown that THC and CBD cannabinoids have the ability to kill cancer cells directly without going through immune intermediaries. THC and CBD hijack the lipoxygenase pathway to directly inhibit tumor growth. As a side note, it has been discovered that CBD inhibits anandamide reuptake. Here we see that cannabidiol helps the body preserve its own natural endocannabinoid by inhibiting the enzyme that breaks down anandamide.

    In 2006, researchers in Italy showed the specifics of how Cannabidiol (CBD) kills cancer. When CBD pairs with the cancer cell receptor CB-2 it stimulates what is known as the Caspase Cascade, that kills the cancer cell. First, let’s look at the nomenclature, then to how Caspase kills cancer. Caspase in an aggregate term for all cysteine-aspartic proteases. The protease part of this term comes from prote (from protein) and -ase (destroyer). Thus the caspases break down proteins and peptides in the moribund cell. This becomes obvious when we see caspase-3 referred to as the executioner. In the pathway of apoptosis, other caspases are brought in to complete the cascade.9

    Even when the cascade is done and all the cancer is gone, CBD is still at work healing the body. Its pairing at CB-2 also shuts down the Id-1 gene; a gene that allows metastatic lesions to form. Fundamentally this means that treatment with cannabinoids not only kills cancer through numerous simultaneous pathways, but prevents metastasis. What’s not to like. One researcher says this: CBD represents the first nontoxic exogenous agent that can significantly decrease Id-1 expression in metastatic carcinoma leading to the down-regulation of tumor aggressiveness.10

    This brief survey touches lightly on a few essential concepts. Mostly I would like to leave you with an appreciation that nature has designed the perfect medicine that fits exactly with our own immune system of receptors and signaling metabolites to provide rapid and complete immune response for systemic integrity and metabolic homeostasis.

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  22. Ron Manuel  October 9, 2013

    Excellent article, that was over my head at times; helpful references; and interesting comments above. If I had been diagnosed with cancer, I’m sure I’d give low carb a try in case it helped the chemo. Yours and other discussions on the topic seem to be in that direction.

    But what about every one of us that have pre-cancerous cells in our body and care mostly about prevention? There must be a comprehensive recommendation that is more specific than exercise and don’t be overweight!

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  23. Steve  October 9, 2013

    Maybe this sounds insensitive, but aren’t high cancer rates an extremely GOOD thing? Cancer is what people die from when they haven’t already died from childbirth, cholera, bubonic plague, shipwrecks, mineshaft collapses, etc.

    The fact that a high portion of the population dies from cancer shows how unbelievably successful we’ve been at solving the problems that traditionally plagued mankind.

    Don’t take this the wrong way- obviously I’d do anything to help a family member with cancer survive. But I do think it’s worth pointing out the historical significance of higher cancer rates. I suspect people in the past would gladly trade life expectancies with us….

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    • Peter Attia  October 9, 2013

      I think understand what you’re trying to get at, but I’m not sure I agree. I can think of a dozen ways I’d rather see a loved one die than succumb to malignancy.

  24. Judy Barnes Baker  October 9, 2013

    I came across something very promising as a cancer treatment that has actually been proven to work on skin cancer. It is a totally different approach that has been overlooked, probably because it is based on an old folk remedy and the researcher is outside the conventional medical establishment. Such claims are usually dismissed as “quackery”, but this doctor actually spent over 25 years and millions of dollars in order to validate his treatment with studies conducted by reputable institutions. He can legally call it a “cure” because he has the proof to back it up. I posted about it here: http://carbwars.blogspot.com/2013/09/is-there-already-cure-for-cancer.html.

    I have no vested interest in promoting this treatment; I discovered it while searching for a way to help a family member, but I have tested it myself and I feel that it deserves consideration.

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  25. Patrik Dahlin  October 9, 2013

    Why not starve the cancer by removing glucose? Most cancer cells need glucose for energy. What about the brain you might rightfully ask? Enter ketosis, then the brain will do fine on beta-hydroxybutyrate.

    But the body will keep a constant blood glucose level even in ketosis you might argue? True, but any MD can give you several ways to lower blood glucose level close to zero with medication (Jeff Volek did inject insulin in ketogen adapted athletes and they did just fine on ketones despite a dramatic drop in blood glucose).

    Has anyone tried this? I’ve written to several Journals about this idea and they all responds it is a total new and interesting way of addressing the cancer issue but non of them feels it is the right stuff for their audience. Please Peter, do something?

    Best regards
    Patrik
    (former R&D Chemist in big Pharma)
    https://www.facebook.com/#!/NewIdeaToCureCancer
    Pleas “like” to spread the word

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  26. Bjorn  October 9, 2013

    Great post even though I didn’t get all of it since it was a bit technical and english isn’t my first language.
    Both my parents died in cancer way too early (mom 54, dad 68). Since dad passed last year I started reading about cancer and I soon realised that a ketogenic, low-carb-high-fat diet probably is a good way of preventing cancer. LCHF as this diet is called here in Sweden is really becoming popular and Dietdoctor.com is one of the largest blogs in the country (I know you’ve met Andreas). One of the best books I’ve read on the subject is “Ett sötare blod” (“A sweeter blood – The health effects of a century with sugar “) by the science journalist Ann Fernholm. http://www.bokus.com/bok/9789127133730/ett-sotare-blod-om-halsoeffekterna-av-ett-sekel-med-socker/
    She explains how insulin effects high levels of igf-1 and that igfbp-1 plays an imortant roll which in turn stimulates tumour growth. She ends the chapter about cancer like this (translated from swedish): “With all the knowledge available about how sugar and high blood sugar can drive cancer, this chapter should  have been concluded with the effect a blood sugar lowering low-carb diet can have on the development of cancer.
    But when I look in the scientific literature, I start to wonder if I’m crazy or at least if I have misunderstood something . Part of me still wants to live in the belief that the scientific community is driven by some kind of logic. Once it has identified a problem – it looks for the solution to that problem. If high blood sugar drives cancer, a blood sugar-lowering diet could probably help chemotherapy to get the upper hand in treatment. It could tip the scale  in the right direction. However, I cannot find any good studies examining this.”
    You would like Ann. She, like yourself, is very credible as a science researcher and is very technical about it but is good at explaining stuff for average Joe’s lke myself as well. She also performs experiments on herself which I know you do too.
    None of my parents were obese. On the contrary, they were both lean and quite athletic (both swimmers in their youth) and they didn’t smoke. They lived healthy lifestyles and were very “outdoorsy”. Mom died in acute myelogenous leukemia which was an effect of the aggressive treatment for her breast cancer one year earlier. Dad died of esophageal cancer. You talk about reducing obesity in order to reduce cancer. Do you believe a ketogenic diet is as effective for the lean person or do you think cancer strikes for other reasons when it comes to lean people? I mean, I’m lean but I eat a ketogenic diet and work out a lot beacause I don’t want to end my life as they did. It’s just not worthy. Do you belive I am improving my odds or am I kidding myself?

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  27. Andrew  October 9, 2013

    The major deviation from evolutionary dietary norms for our species which has occurred in the past 100 years has coincided very neatly with the exponential rise in rates of both heart disease and cancer. It would seem to be the most obvious place to look if one applies the principle of Occam’s Razor to the question of “what’s gone wrong.” Add in endocrine disruptors and the altered lipid profile of factory-farmed meat, plus what we’re now finding out about the new GMO wheat, and the answer would seem to be self-evident . . . but the message is being actively suppressed by those with SO MUCH TO GAIN from the current paradigm. As ever, “Cui Bono?”

    The politically-correct but dead WRONG dietary disinformation still parroted by National Public Radio has resulted in my now refusing to fund them with my membership–they will not acknowledge alternative hypotheses.

    You are doing vital work here–my thanks!

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    • Alexandra M  October 10, 2013

      I still support NPR, but you’re right: some stories make me want to throw the radio out the window, like the one where doctors were taking cooking lessons at a culinary institute (so they could better tell their patients about “healthy” eating). First up on the menu? “Recovery” bars containing marshmallows…

      “We’re going to try to take advantage of what’s called an anabolic window, a specific period of time after the workout where we can give them the best gains,” he says.

      The first course will be a “recovery” bar with whole grains, spices and marshmallows to deliver some quick sugars. Then there’s the frittata that Solanki is laboring away at, stuffed with baby zucchini, red bliss potatoes, red bell peppers, parmesan and feta cheese and spinach. It’s a feast, says culinary student Briana Colacone, designed to refuel with lean protein and carbs. “It’s going to be really good,” she says.”

      *sigh*

    • Peter Attia  October 10, 2013

      Yes, this is frustrating. Imagine how confusing this is for the public?

  28. Caitlin  October 9, 2013

    Dear Peter,

    I almost jumped out of my chair at work when I saw this post come through my email. I knew you would start covering cancer eventually and was trying to be patient, so I just want to say I’m really happy to see the beginning post. I’m also in the Seyfried camp and have followed metabolic cancer research for awhile now. I lost my mom to GBM three years ago so I follow the research on brain cancer in particular. My mom was a nurse practitioner in vascular radiology at Duke and meticulously followed a “heart healthy” low fat diet. I recently came across a cardiologist who is in remission from GBM (3 years) and had also done a lot of research on his diagnosis. He found an intriguing study by a Johns Hopkins-trained cardiologist who now practices in Israel. This doctor had collected data on 23 invasive radiologists and cardiologists who had developed tumors, of which 17 were GBMs on the left side of the brain (my mom’s was also on the left side of her brain as was the cardiologist’s who was not included in the data). Perhaps I am using facts to suit theories instead of theories to suit facts, but even if this study doesn’t demonstrate anything conclusively I think it is a very alarming cause for pause. The current literature on this topic seems to blame the cardiologists’ exposure to radiation, but I thought immediately about the low fat diet cardiologists typically endorse (and live by).

    I asked the cardiologist if he had tried the ketogenic diet and he said he had. He also said that the “keto breath” side effect was particularly potent in his case (to the point where people around him noticed his odor) and he recognized the smell from treating diabetic patients with ketoacidocis. I don’t know why this seems significant to me, but I had only a mild and fleeting experience with this side effect while adapting to nutritional ketosis. I wonder if there is some kind of link here to people who adopt ketosis in an earlier/healthier phase of life? It also could just be a random side effect that varies by person but I thought it might add some anecdotal food for thought to your research.

    Anyway, I also just wanted to say that I’m appreciative of your work and look forward to learning more about your thoughts and research in the next post.

    Caitlin

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    • Peter Attia  October 10, 2013

      Caitlin, I’m very sorry to hear about your mother. I can understand how this would generate so much interest for you. Hopefully I can point you in some interesting directions over the next few months.

    • Amy B.  October 10, 2013

      Caitlin,

      The loss of your mother is even more devastating considering she worked at Duke, which is where Dr. Eric Westman’s clinic is. (If you’re not familiar with him, he’s one of the top proponents/pioneers of low-carb/ketogenic diets. His focus is weight loss and metabolic syndrome, but I’d be surprised if he wasn’t quite familiar with Seyfried’s work and the implications of ketosis for cancer.) He and the cardiologists are probably only a few hundred feet away from each other physically, but galaxies apart in approach to medical practice.

    • Caitlin  October 10, 2013

      Thanks Peter, I look forward to it.

      Amy, yes Duke is on the cutting edge in brain cancer research. I’m not familiar with Dr. Westman, but my mom was treated by Dr. Henry Friedman at the Brain Tumor Center and Dr. Allan Friedman was her surgeon. I do agree that it’s unfortunate that these links were not well understood enough for the two departments to collaborate. My mom worked at Duke for 20+ years and had surgery the same day as Ted Kennedy. She had worked as an OR nurse earlier in her career for the surgeon and everyone kept telling her she was Duke’s real VIP. Her colleagues from all over the hospital went above and beyond for her and for our family. If they had thought about the metabolic links they definitely would have discussed it with her.
      Most of all, my mom thought she WAS following a cancer prevention diet, so she never thought to try and change it once she was diagnosed. My brother and I joked that she was a rabbit because she ate so many colorful vegetables. She loved preventative medicine and read all kinds of books about it. To her credit, she did not have as much difficulty (not saying it was easy, just in a relative sense) with surgery recovery and enduring a lot of the chemo/radio treatments because of her otherwise good health (non-smoker, no diabetes, no high blood pressure, etc.). Unfortunately, I’m finding out a lot of her diet information was wrong, or at least it was missing a very significant component (FAT). But I try not to get too bogged down in the what ifs (would lose it if I did). Dr. Seyfried’s book came out in June 2012 and my mom was diagnosed in May 2008. She lived for exactly two years, which was pretty much the max as I understand it (99% of GBM patients don’t survive past 2 years). I’m happy to hear that is starting to change. In 2007, a good friend of mine lost his mom to GBM in a matter of 24 hours (she died in the OR). In that respect, I feel very lucky to have had those two years with my mom. I think she would be really happy that preventative medicine is making more progress on the cancer front. If she were still here I think she would be leading the charge to for cardiology/radiology to collaborate with oncology.

  29. Andre  October 10, 2013

    Excellent blog post as always – however compliments to the readers, I must say i am startled to see how many people apparently have discovered and read Seyfrieds book, its a tough read, I read it as a preventive measure and thought nobody else would read it due to its density of information. Now I feel like a nerd…

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    • Peter Attia  October 10, 2013

      Yes, Andre, I think it’s safe to say this is the dorkiest blog out there…

  30. Fiona  October 10, 2013

    Dr. Abrass falsely links, in part, the reduction in the death rate of cancer since 1950 to mammography use when the most reliable, non-conflicted (by vested interests) studies found no discernible reduction in breast cancer mortality from its use (read Rolf Hefti’s e-book “The Mammogram Myth: The Independent Investigation Of Mammography The Medical Profession Doesn’t Want You To Know About”). He also puts much hope into gene sequencing and other genetic notions when it was found that not one disease has ever been successfully tackled upon knowing the entire human genome.

    Abrass is merely another spoke of the medial orthodoxy who’s been teaching an erroneous, unscientific approach to healing in their doctrinaire mechanistic reductionism model. Hence, the war on cancer has been little more than complete failure. And not one chronic degenerative disease has ever been cured by the idiotic treatments of toxicity of mainstream medicine. Who, in their right mind, would ever expect a cure from such an unscientific approach? Modern medicine is great at bragging about their overblown advanced treatments. And they are great at denying and hiding some of the most severe harms of their products and services -due to their influential marketing few people are even aware of this.

    With conventional medicine, which is a huge commercialized business, it’s mainly about treating disease (true prevention is practically meaningless to them), and the supposed looking-out for a cure. It’s almost all propaganda, helping for the unsuspecting public to keep donating huge sums of money to a illogical, profit-hungry business industry of disease to allegedly finding a cure. Keep dreamin’… or start to wake up.

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    • Peter Attia  October 10, 2013

      Fiona, I’m pretty sure you didn’t read the same post I put up. You must have ready something else. I’ve read and re-read your comment twice (breaking one of my rules), and I’m convinced you’ve missed the point by about 175 to 185 degrees.

    • Alexandra M  October 10, 2013

      “With conventional medicine, which is a huge commercialized business…”

      Unlike alternative medicine, which is well known for providing its treatments free of charge. Of course, it’s easy for alternative medicine to do this, because practitioners don’t need to pay for medical school, or for a medical license, and the makers of alternative “remedies” don’t have to spend millions of research dollars on clinical trials, or demonstrate the efficacy of their treatments to the FDA, or spend a lot of money creating new molecules in a laboratory when the ingredients they use are available on the nearest highway median.

      Wait – they’re NOT giving the treatments away?

      What a rip-off!

    • Fiona  October 11, 2013

      @ Dr. Attia: What exactly did I miss by such a wide margin? Please explain because I can’t see it as the post is about the war on cancer and my comments took a strike at the heart of the matter.

      @ Alexandra M: Does me stating a fact (“With conventional medicine, which is a huge commercialized business…”) that the opposite (or anything else) applies to another related industry? Sounds like, based on your defensive illogical response, that you’re offended by what I posted.

  31. Eric  October 10, 2013

    Hi Peter,

    Was going to write and plead with you to read Seyfried’s book about cancer as a metabolic disease – but looks like you’re aware of his work – thrilled about that.

    Just finished listening to your Ted talk again. (It didn’t make your list but it’s top ten in my book :)

    How shocking that one of our great artists, Tom Hanks, has Type 2 diabetes. And how disappointing that all he mentions about controlling his disease (that I’ve heard) is his weight – exactly the problem you discuss in your presentation.

    How great would it be if he put his disease into remission with a ketogenic diet and then told the world about it?

    I wish he knew your journey – insulin resistant in mid 30′s – but healthy later with a radical change of diet. So if anyone out there knows a guy, that knows a guy… that … knows Tom Hanks, please let him know!

    (reply)
    • Peter Attia  October 10, 2013

      Yes, Eric, I heard this the other day. Too bad. I’m sure the last thing Mr. Hanks would want is to hear from random folks like me. I do wish him well.

  32. Monting  October 10, 2013

    Peter,

    Just want to thank you for all that you do. Your posts and talks and the approaches you take are what killed my fat-phobia, and helped me gain back my health. “Dorky”? No, they’re detailed and informative!

    Really looking forward to your comments on Thomas Seyfried’s work, and the work coming out of NuSi!

    (reply)
    • Peter Attia  October 10, 2013

      Thank you, Monting. Whether “dorky” or “nuanced” or “detailed” … I like it!

  33. Alexandra M  October 10, 2013

    It’s heartbreaking to hear all these stories about loved ones lost to cancer. I can’t imagine how awful it must be, given how awful it was losing a beloved cat to cancer earlier this year. I asked the veterinary oncologist how ketogenic diet could be implemented for cats, who are obligate carnivores to begin with (but you’d be amazed at the quantity of grain put into ordinary cat and dogs foods). He looked at me like I was nuts, even though I handed him a journal article about ketogenic diets to starve tumors of glucose.

    Two months later, when my cat was having difficulty eating, I began mixing some butter into her food to make it easier for her to swallow, and to try to get some extra calories into her. When I told the vet he said, “Well, maybe those aren’t the best calories.” Which tells you a lot about how deeply entrenched the idea is that nothing – absolutely nothing – is worse for you (or your pet) than eating fat, not even slowly starving to death.

    (reply)
    • Peter Attia  October 10, 2013

      If you can find any solace in this, I’ve interacted with a few vets who have taken this approach with pets. They claim impressive results, though I don’t know if such outcomes are actually studied rigorously.

  34. Brian  October 10, 2013

    Peter, do you see any health benefit and/or drawbacks to a diet based primarily on “healthy” plant-based fats (nuts, seeds, olive oil, avocado, coconut) versus animal-based fat sources (lard, bacon, dairy, eggs, beef)? Thanks!

    (reply)
    • Peter Attia  October 10, 2013

      I don’t think so. Probably more of an individual question, rather than a general one, though.

    • Caitlin  October 10, 2013

      Brian, I would note that fish seems to be one of the more important sources of fat. If you read more about omega-3s there is a difference between the omega-3s found in flax seed and the omega-3s found in fish. ALA versus DHA and EPA in particular if you are looking for some keywords. Not sure if your question comes from a particularly vegetarian/vegan point of view, but if there was one animal to eat for its fat it would be fish. You could also just supplement with a high quality fish oil. Not sure if Peter agrees with this but he does supplement with fish oil so I’m guessing he sees some further added benefit from this type of fat (or he’s just in the middle of experimenting).

    • John U  October 18, 2013

      Brian,

      I have spent the last 50 or more hours reading the blogs and comments of Peter Dobromylskij (Hyperlipid) at http://high-fat-nutrition.blogspot.ca/. This blog is the MOST technical that I have ever seen and includes a lot of biochemisty in the blogs and the comments. Most of the commenters appear to be well educated scientists. I would recommend to start reading the blogs at the beginning, i.e. circa 2006, before GT book. Peter D is a high fat low carb proponent, but not too keen on veggies or PUFA’s inlcuding omega oils. He does supplement W3, but only a little. Check out the blog – very very interesting discussion, especially if you can persist in spite of the chemistry.

  35. Bill  October 10, 2013

    Not specific to cancer, but two excellent advocates of low carb, meat-based, grain free diets for cats are Drs. Elizabeth Hodgkins and Lisa Pierson. They cite some decent research, but as in human medicine research is dominated by commercial interests, especially the huge pet food industry. More impressive is their amazingly successful clinical experience. Diabetes and weight loss, of course, plus GI problems, allergies, urinary tract problems, and much else.

    http://www.amazon.com/Your-Cat-Simple-Secrets-Stronger/dp/0312358024/ref=sr_1_1?ie=UTF8&qid=1381440613&sr=8-1&keywords=hodgkins+your+cat

    http://www.catinfo.org

    My current thought is that while cats are clear carnivores who handle carbs extremely poorly, dogs are more like us, having shared food with us for eons: tolerant of whole food carbs to a greater or less extent but not doing well at all on refined grain-based modern foods. Both of the vets I mentioned discuss the unique physiology of cats in relation to dietary needs and tolerances.

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  36. Joshua  October 10, 2013

    Hey Doc! Have you looked at the research regarding the effect of various fat sources have on tumor growth? Specifically, ketosis seems only beneficial if it’s (mostly?) fueled by saturated and mono-unsaturated fats.

    I heard about it from this blog post: http://high-fat-nutrition.blogspot.com/2013/08/starvation-and-cancer-growth-sauer-vs.html “Palmitic, stearic and oleic FFA supplementation was inactive in promoting tumour growth. Linoleic and arachidonic promoted growth, really well. That is very scary.”

    I’m frankly not smart enough to understand the significance of everything at that link, but those two lines stood out at me.

    Thanks! I enjoy your posts.

    (reply)
    • Peter Attia  October 11, 2013

      Joshua, it’s not clear to me that this is necessarily true. Cancer is a pretty tricky disease, as I’ve learned from my personal research in oncology. What happens in vitro or in vivo in a mouse does not necessarily (or often) translate to a human.

  37. guy ben zvi  October 11, 2013

    Hello Dr. Attia
    Have you heard of the Warburg effect? http://en.wikipedia.org/wiki/Warburg_effect
    I have been talking to oncologists for years why they don’t test “starvation” like ketogenic states with cancer patients. Although oncologist researchers that know the Warburg effect told me it justifies research there have been to the best of my knowledge zero experiments with humans to date. However just recently a clinical study of brain cancer treatment with a ketogenic diet has been started in Israel in Ichilov hospital. So finally someone is paying atention to dear old Dr. Warburg and his simple idea.
    http://www.cancer.gov/clinicaltrials/search/view?cdrid=669338&version=HealthProfessional&protocolsearchid=6891142
    What do you think?
    Guy

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  38. Mark  October 11, 2013

    Hi Peter,

    Do you think there is any basis to low-carb diets being a) preventative in avoiding cancers, and b) recuperative in recovering from them? There seems to be some official looking information to this effect.

    http://www.foodconsumer.org/newsite/Nutrition/Diet/low_carb_high_protein_diet_may_help_fight_cancer_0617110701.html
    http://www.healthnewstrack.com/health-news-1451.html
    http://www.sciencedirect.com/science/article/pii/S0005272810006857
    http://cancerres.aacrjournals.org/content/early/2011/06/10/0008-5472.CAN-10-3973.short

    Cheers, Mark (from Perth Australia)

    (reply)
    • Peter Attia  October 11, 2013

      Mark, I don’t know the answer, at least not in the same way I know when drop a tennis ball that it will hit the ground, but I do plan to address these questions eventually.

  39. Diane Russell  October 12, 2013

    Hello Dr. Attica – thank you for your work! Curious- have you ever come across the work of Dr. Mark Rosenberg? I came across him while researching treatment options for my mom’s st V lung cancer. I was looking specifically for options that would include integrating ketogenic diet and found his facility in Boca Raton, FL -
    http://www.antiagemed.com/programs/integrative-advanced-stage-cancer-therapeutics.php
    He mixes alt therapies with low dose chemo (chemo customized thru tumor testing at Weisenthal Cancer Group – weisenthalcancer.com).
    Finding treatment that emphasizes nutrition is difficult as you know and finding a nutritionist/dietician that doesn’t practice the standard model is rare. Even mention “Ketogenic” and I either get a puzzled look or a lecture on how dangerous it is to be on long term. Hoping you had some thoughts/comments. Thank you!!

    (reply)
    • Peter Attia  October 13, 2013

      I am not familiar with him, Diane.

  40. wukang  October 12, 2013

    Peter,

    Just in case you didn’t notice, ADA has officially removed the support for “balanced diet” for diabetes.

    http://care.diabetesjournals.org/content/early/2013/10/07/dc13-2042.full.pdf

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    • Peter Attia  October 12, 2013

      Yes, I did see this. Very interesting. Definitely a step in the right direction.

    • Boundless  October 13, 2013

      As I read the recent ADA position paper, I’m not sure I’d characterize it as a full step in the right direction.

      My posture on T2D is that it’s a totally optional ailment that is trivially avoided with diet, is fully reversible with diet at the metabolic syndrome and pre-diabetic stages, and is often reversible after that, or is at least fully manageable primarily with diet. T1D is another matter.

      The paper reads to me more like liability management – being mindful that the ADA has been, for decades, advocating a diet that causes T2D and keeps people on meds. The ADA is giving deminimus acknowledgement to what the grass roots have already figured out. This new ADA diet only slightly reduces the harm of the old one.

      This quote pretty much says it all:
      Page 2: “People with diabetes should consume at least the amount of fiber and whole grains recommended for the general public.”
      We might ask Dr. William R. Davis, former diabetic, to opine on that :).

      Page 14: “There is no standard meal plan or eating pattern that works universally for all people with diabetes.”

      Notice that they fail in that sentence to differentiate T1D and T2D. The ADA seems to do that when it suits them.

      New cases of T2D can easily be made to vanish.

      T1D is going to be with us for some time, until its trigger is found and eliminated.

      The ADA calls for more diet research. I read that as: today’s tiny half step means the ADA isn’t going to do anything substantial on diet and T2D for decades. I considered them to be a public health menace prior to this paper, and still do.

    • Peter Attia  October 13, 2013

      I think I’m mostly pleased that they have at least acknowledged that the dogma of eat all carbs, eat no fat has no evidence supporting it.

  41. Todd  October 12, 2013

    Fasting Glucose – Question
    Background – Started LCHF in response to high CACS score >900 and other related metabolic syndrome symptoms.
    My fasting glucose has slowly risen from ~ 4.5 and now remains stubbornly high (5.5-6.5) in spite of being LCHF for the past 3 yrs and a relatively active lifestyle (avg 1.5 hrs/day).
    Fasting ketones have remained steady between 1.2-2.5.
    Current BMI 26.5, target <25.
    Would like to find a way to reset my avg blood glucose in the 4.5 range
    Would like to lose the last stubborn 5kg around my midriff.
    Any suggestions would be greatly appreciated. Thank you for your blog.
    Any suggestions on how to break through this plateau and reset blood glucose levels would be appreciated.

    (reply)
    • John U  October 18, 2013

      Todd,

      There is a fair amount of discussion on the blog Hyperlipid (http://high-fat-nutrition.blogspot.ca/ on the subject of fasting BG. There is reason to believe that the liver is generating some glucose to supply minimal requirements early morning. Glucogenisis amount varies with individual. It is not something to be concerned about, but please check it out. The discussion took place in 2008 somewhere so you will have to do some searching.

  42. Per Holmlöv  October 12, 2013

    Peter
    I had an operation for prostar cancer 1,5 yrs ago and am free from problems now. My Testosteron levels are still low. I am 72 more fit Than my age group. Hos does low carb or ketosis influence Testosteron ? Do you know or can you guess ?

    (reply)
    • Peter Attia  October 12, 2013

      I don’t know from a clinical trial standpoint, but in me I’ve experienced a 50% increase in free T and total T. I’ve also reduced my training volume, which be a greater driver.

  43. Marilyn  October 12, 2013

    Some random thoughts:

    1. A couple of items in the Jul/Aug 2013 DISCOVER:

    “Evolution in Overdrive” (p. 20) notes that in the past 10,000 years, world population has gone from about 5 million to more than 7 billion persons. This very fast, very recent population expansion has resulted in “millions of rare gene variants . . . gene variants that might make us more prone to illness, or simply less likely to survive.”

    Maybe the introduction of agriculture didn’t encourage cancer by, as is often suggested, introducing “Neolithic” foods to which we aren’t adapted, but by providing abundant food that helped support a population explosion, an explosion that got us a bunch of new DNA mutations?

    But according to “Cancer: The Long Shadow” (pp. 62ff), cancer was with us long before the introduction of agriculture. “. . . the fossil record reveals a disease that may have been with us since prehistoric times.” The author’s closing remarks: “Yet running beneath the surface there has been a core rate of cancer, the legacy of being multicellular creatures in an imperfect world. There is no compelling evidence that this baseline is much different now than it was in ancient times.”

    2. According to Dr. Abrass, “. . . the most preventable cause of cancer seems to be obesity.” Has this been proven? I did an internet search for “does obesity cause cancer?” and saw the words “linked to” and “associate with.” Granted, I didn’t check all the results of the search, but “linked to” and “associated with” are not the came as “causes.” My hunch is that actually proving that obesity, in and of itself, causes cancer might be next to impossible.

    3. Has mammography really saved that many lives? I can see where cessation of smoking can save lives, but from what I’ve read, mammography is perhaps not the life-saver it is promoted to be. The reality seems to be that a whole lot of women have to be scanned repeatedly for a whole lot of years to save one life. Meanwhile, all that screening can result in false positives, unnecessary full-out treatment of something that would never have been a problem, possible generation of new cancers from the extra radiation, and so on.

    (reply)
    • Peter Attia  October 13, 2013

      Marilyn, I agree with you hunches. Specifically, I doubt that obesity, per se, causes anything, let alone cancer, except in rare cases. And this includes T2D. But there is a strong association and underlying causative issues to both obesity and metabolic disease. Cancer is no exception. Additionally, I agree there is great controversy around the big 3 screening tools: mammo, PSA, and colonoscopy. At worst, there is no improvement in stage-adjusted survival, given lead time bias. At best, there may be a modest improvement. I suspect this is due to the same problem that plagues the statin trials — poor stratification of subjects and failure to identify a priori who is really at risk to warrant intervention.

    • Bill  October 13, 2013

      Cancer screening is, to me depressingly parallel to low fat/low calorie ideology: an overwhelming push by medicine and government in the absence of any real data to support it. And virtually no honesty about this in the propaganda or the individual advice provided within the health care system. Same with flu shots and so much else.

      With cancer screening, it’s not clear to me what such data could even be, e.g., what “data” can tell you how to weigh, say ten women losing their breasts, or a hundred women suffering lymphedema or suffering the effects of radiation or chemo, against, say, one woman possibly having her life extended? Unless screening tests become virtually 100% specific (unimaginable at present) or, as Peter suggests, the small number of truly high risk people can be identified some other way, with screening strictly limited to them, it will always be a personal judgment and different choices will be reasonable for different people.

      With protocol-driven, guideline-based medicine strongly in ascendency, and doctors incentivized to follow them, there seems to be little prospect for such free, individual choices for some time to come. My own doctor has acknowledged to me that he is graded on how well people like me follow the guidelines and submit to colonoscopies, etc. Fortunately he’s a very good guy and supports my personal decision to opt out, happily trading off a tiny chance of benefit against a much greater chance of getting unnecessarily sucked into the medical mill and quite possibly being harmed in the process. Others might reasonably make different choices, though I think far fewer would if they knew how little evidence there is to suggest that the benefits outweigh the risks.

    • Amy B.  October 15, 2013

      This response isn’t to Marilyn, but to Peter…can’t seem to find a link to leave a reply to his comment.
      Just wanted to say THANK YOU, Peter, for this: “I doubt that obesity, per se, causes anything, let alone cancer, except in rare cases.” I’m so tired of obesity constantly being cited as the *cause* of all our society’s medical woes. It’s like you said in your TED talk, and like so many others in the low-carb/Paleo worlds have suggested: obesity is rarely, if ever the *cause* of chronic disease, but rather, it’s simply one more *effect* of fuel partitioning and overall metabolism gone awry due to our physiologically incongruent diets and lifestyles. I understand that adipose tissue can be considered an endocrine organ, so it’s obviously not completely benign, but for us, as a population, to keep laying the blame for everything from heart disease to rainy days on obesity just perpetuates the moral judgment of the obese as lazy, gluttonous, greedy people who sit on the couch all day with one hand in a bag of chips and the other on a bottle of Mountain Dew. It’s the easy way out, and, of course, dead wrong in most cases.

    • Peter Attia  October 15, 2013

      I couldn’t have said it better, Amy. Thank you.

  44. Amanda  October 13, 2013

    Thank you for everything that you do! People like yourself, Gary Taubes and Robert Lustig are heros of mine who I believe have added 20 – 30 years to my expected lifespan! The book Good Calories, Bad Calories changed my life and your blog is constant reminder to help keep me on my new eating path!
    I was at the mall today and a group of people were selling things like candy apples and cotton candy to raise money for breast cancer. I wanted to go up to them and explain that what they are selling is one of the main causes of the cancer that they are trying to cure. Its disheartening to think of all the money directed at the wrong research, but I think it is so wonderful that NUSI has been founded. Again THANK YOU for all the time you spend sharing this message with people like myself, who would be slowly killing ourselves day by day without having a clue! My life was changed several years ago and this is my first time ever writing a comment. If you or your colleagues ever feel discouraged that the message is not being accepted fast enough, remember there are tons of us out here who you have changed our lives and we have just been silently thankful! The government and associations will be the last to change their tune, but the individuals are starting to learn and understand! THANK YOU!

    (reply)
    • Peter Attia  October 14, 2013

      Thank you, Amanda, for your kind words. The tide will change not because of the Gary’s, or Rob’s, or Peter’s, but because of you and everyone else.

  45. Jeff Johnson  October 13, 2013

    …………………
    ……………………..
    ……………………..

    Carb Load Experiment

    After eating 10 cups grapes – my glucose measured 225 – I thought about this a little bit and decided it was better to have a high – temporary – glucose reading than to secrete excess insulin to keep it lower – which I suppose my pancreas could easily have done if it wanted to

    I suppose it knows what it is doing ?

    (reply)
  46. Andrew Logan  October 14, 2013

    It’s interesting to see that the ADA is starting to hedge it dietary bets a bit. Down here at the bottom of the world, our equivalent, Diabetes New Zealand still seems a bit confused. They say this: “•Carbohydrate: has the most direct impact on blood glucose levels and comes form both sugars and starches. Where possible sugar has been replaced or reduced.All dried fruit, juice, flour and other starchy foods (including potato, rice, flour and so forth) will have an effect on blood glucose levels so serving size counts” but then in their recipe section get quite carried away with recipes for muffins, hamburger buns and pasta etc. The best is their “special fruit cake” with ingredients as follows:
    •1 kg mixed dried fruit
    •1/2 cup boiling water
    •1/2 cup orange juice
    •1 cup nuts
    •2 cups wholemeal flour
    •2 tablespoons gluten flour or extra flour
    •3 teaspoons baking powder
    •3 eggs
    •1/4 cup slivered almonds
    •2 tablespoons sherry
    Sorry, but it makes me feel ill! NZ is not far behind the USA in the T2D/IR/obesity stakes and sadly the unfortunate people who have to live with these conditions have little hope of getting the advice they need unless they strike out on their own. Thank God (seriously) for Gary Taubes, yourself Peter, AND Tim Ferris.
    Oh, ad I’ll write to Tom Hanks if you won’t – do you know his address?

    (reply)
  47. Scott B  October 15, 2013

    Dr. Attia – I just finished “Grain Brain” by David Perlmutter. What are are your thoughts about gluten vs, just the excess carbs (that is, living non-keto) as causative agent in the various degenerative diseases.
    Thanks,
    Scott

    (reply)
    • Peter Attia  October 15, 2013

      Not enough expertise to comment.

  48. Dominique  October 15, 2013

    “Tim Ferris and I were having dinner” – Can I tell you how excited I was at the thought of you two collaborating? I’m not terribly familiar with Ferris’ work, but from what I have seen he seems to have incredibly effective (if unorthodox) methods, and I have a lot of respect for him.

    On another note, this post was great and I look forward to reading more on your thoughts regarding cancer. I only just got my Bachelor’s in English, and nutrition is more of a hobby for me, so these posts always challenge me to learn more and do even more of my own research (and it makes me even more excited about the possibility of getting my graduate degree in a health-related field!).

    Again, thank you…your site is a wonderful resource!

    (reply)
  49. Teresa  October 16, 2013

    Thanks for you informative posts. Wonder if you can comment on Seyfried’s idea that the very models of 1) accumulated mutations causal in cancer and 2) metastasis, are questionable – supported, I believe, both by the heterogeneity of tumors and application of Occam’s razor (i.e. too complicated both with regard to random multiple mutations as well as multiple de-differentiation/re-differentiation of cancer cells required to posit that cancer cells seed other organs). Instead he interprets murine data to suggest that in fact there is a tipping point when the physiologic and metabolic loads over time cause energy systems (specifically mitochondrial respiration) to “go awry” globally and hence multiple cancers can arise, with numerous associated but not causal anomalies? I ask this in part out of theoretical interest, because of your background in immunologic, molecular research, and in part to wonder whether, if one entertained this hypothesis, it would be possible to avoid lymphadenectomies and extensive surgeries in favor of more conservative interventions (although as I type I’m already discounting the question as I recall that he does suggest modified macrophages travel and form distant niduses, perhaps giving some credence to the desireability of pruning the lymphatic system – yet seems dangerous to me nonetheless!).

    Beyond that speculation, can you recommend any nutritionists with experience managing the restricted calorie ketogenic diet clinically for cancer, am needing some assistance with this and with diet cycling, as recommended by Seyfried – despite being low carb for almost 20 years since my first introduction to the concept by Barry Sears, I find myself with a diagnosis and am wanting to hit it hard with diet and needing some support. Thanks in advance and looking forward to more.

    (reply)
    • Peter Attia  October 18, 2013

      Teresa, these are great questions and I’m not sure I know the answers. But I’m all eyes/ears, for both personal and professional reasons. A dear friend’s wife is battling breast cancer and this very question (the nature of mets) is germane to her treatment choice. It’s a huge struggle for them, and I wish I could offer more insight. If you haven’t read it already (you probably have), you will appreciate “Emperor of all Maladies: The Biography of Cancer,” especially the chapter on Halsted and the radical mastectomy. You may be right re: the utility of aggressive lymphadenectomy.

    • Hemming  October 18, 2013

      Hi Teresa,

      I know David Jocker http://www.drjockers.com/category/health-news/cancer/ believes in the treatment of cancer with a ketogenic diet. I’m not exactly sure how he runs his practice but its worth checking out.

      All the best!

    • Justin W.  October 19, 2013

      Teresa, My son is fighting a form of brain cancer and we’ve recently decided to put him on a ketogenic diet. We work with Carrie Loughran of Ketocare (www.ketocare.com). She is an RD and has decades of expertise in the diet for epilepsy and is now starting to work with a few cancer patients. You might also be interested in Miriam Kalamian. She’s not an RD but has an MS in nutrition science and worked with Seyfried on taking her son on a KD several years ago. So she has a lot of personal experience and now is a KD coach for cancer patients. She’s here: http://www.dietarytherapies.com and an interview with her just a couple days ago is here: http://www.thelivinlowcarbshow.com/shownotes/8826/738-miriam-kalamian-offers-hope-to-cancer-patients-with-the-ketogenic-diet/

  50. MarkM  October 17, 2013

    I lost my first son at two years of age to GBM. After quickly coming to the same conclusion that you outline here (successful treatment means extending life by a few months), we chose to eschew aggressive treatments and worked instead on making our boy’s remaining days as enjoyable as possible. At first, that meant a trip Disney World and lots of trips to the petting zoo. At the end, that meant morphine at home in his own bed surrounded by those who loved him. For what its worth, those physicians who promised the least but could discuss the reality of the situation with unblinking candor remain in my highest esteem.

    I look forward to reading your next post on this issue.

    (reply)
    • Peter Attia  October 17, 2013

      Mark, I don’t even possess the vocabulary to describe how sorry I am and how upsetting this is. I was, for reasons I don’t fully understand, drawn to pediatric oncology, even while in engineering school, and this eventually led to my decision to go to medical school, rather that engineering grad school. However, until I had a child of my own I don’t think I could even half understand what a parent like you goes through. I obviously still can’t.
      Sometimes the people around me — wife, colleagues, friends — ask why I’m such a relentless freak in my work life. Why can’t we slow down, just a bit, they ask? I think one of the reasons to keep the pedal down all the way is the knowledge that every day we don’t have something to offer cancer patients based on an improved understanding of the disease is another day of this kind of sadness. And the same is true for all metabolic diseases.
      Thank you for sharing your story. I hope one provider of healthcare is reading this and gleaning from it your wisdom.

    • paul  November 4, 2013

      Response to Peter. The stuff you are doing with Gary, Dr Lustig, the low carb community, etc., is really important. Even if the alternative hypotheses all turn out to be wrong, it’s clear that you (collectively) are adding critical thinking to the mix, i.e., you are improving the robustness of scientific debate (which it sorely needs). Keep at it. These efforts really do affect the well being of so many people.

    • Peter Attia  November 4, 2013

      Thanks very much, Paul.

  51. milo  October 18, 2013

    dear Peter,

    hope You might be interested in my resume of a popular explanation about some of my cancer research,
    trying to use ordinary expressions,

    those strange sicknesses sadly became an unnecessary violent public health issue,

    ¿ how can we understand the creation of cancerous cells ?,

    out of several trillion body cells, every singular one is collaborating with a mutual benefit, for one and the same body,
    (90% of those cell types are found all over the earths biomass),
    our proper body cells, can achieve to ‘copy’ themselves as much as 80 times !,

    just take your passport and make a copy, and a copy of this copy, and so on, eighty times, and if there wasn’t enough ink, (‘ genetic material ‘), you won’t be able to read the illegible name, nor the numbers,

    and the related cells become confused about which body they are working for,
    begin to struggle and to serve themselves,

    and are therefore recognized as cancerous cells,

    the ‘ink’, the material necessary to complete the copies, in real life, are the so called aminoacids, mostly supplied by natural vitamins, etcetera,

    (and without putting any oil (ink) into an engine, normal performance, will become critical, very soon),

    ¿ by what means do our bodies get their essential building blocks ?,
    (aminoacids and minerals, (oil for the engine, ink for the printer)),

    to guarantee our organs can function correctly, assure our body can preform its normal tasks, maintain the ability to carry on, assembling genetic structures, proteins, digestive enzymes, hormones, (some natural vitamins), etcetera,
    endless vital micro- and nano-processes must just happen fine, with a typical and sane outcome,

    the majority of those aminoacids, are taken in by the means of natural vitamins, etcetera,

    the existing 22 aminoacid molecules, (almost living structures), composed mainly by few hydrogens, nitrogen, oxygen and carbon atoms, which attract and repel themselves, in a steady dance, (awash in cosmic radiations),
    several are essentially unstable to temperatures higher than 42° degrees celsius, (various of those needed by or bodies),

    their balanced interatomic shake, is where life originates,
    with vibrations comparable to the sound of a musician,

    and a protein, for example, assembled with thousands of those molecules, creates the impression of an orchestre,

    some, which due to their temperature responsiveness, start to stutter, with as little as 42° degrees celsius,
    (while pasteurizing is 80° and cooking 100°),

    often the reason, why those active fundamental building blocks can loose their vitality, and go numb,

    with an awful problem emerging to many biological processes !,

    ¿ to what degree are our bodies building blocks, those vigorous aminoacids, animated ?,

    ¿ do they have ‘ gods divine breath of life ‘ ?,
    which is so easily destroyed, unachievable to be restored, and even more hopeless, to be originated,

    ¿ are those molecules just melted down to passive, increasingly lifeless structures, due to excessive temperatures ?,

    ¿ are we ‘ homo ignis incendium ‘, the only mammal species using fire to ‘prepare’ food ?,

    what so ever, we are taking about mayor implications, in case those vital, force giving, aminoacid molecules fall short,
    cells can easily turn cancerous,
    (with alzheimer, diabetes, etcetera, just on a brink),

    but after thousand million years of trials and errors, biology creates the impression to have regulated this setback with 3 000 000 000 dendritic lymphocytes, (or probing cells, who search for those ‘disoriented’ cells), fundamental parte of our bodies immune systems, which break, those cells turned cancerous, to pieces and recycle their proteins,

    with the only inconvenient, that those dendritic ‘fighter cells’, as well, need aminoacids, delivered by natural vitamins,

    in resume, it simply may be of greatest importance to consume natural vitamins by means of minimum 20 to maximum 50% raw food, (fruits, salad, nuts, honey, etcetera, that never suffered temperature),
    just to allow biological methods to assimilate enough essential building blocks,

    that’s no news at all !,

    on the other hand, ¿ how come that year after year we consume far less than twenty per cent, (in an average global scenario), using artificial, lifeless drugs and vitamins, on a regular base, instead ?,
    clearly i’m oversimplifying biological phenomenons,
    true to life, ‘miracles’, are everlasting more entangled and increasingly complex,

    to give just one example,
    amino acid containing substances, are not barely supplied by vitamins, but by proteins, (which themselves are built with those building blocks), etcétera,

    misunderstandings are difficult to be avoided,
    too many biological functions are partially unknown, or not radically comprehended, still,

    but the twenty precursors, our bodies are based on, are fairly well understood,
    half of which we have to take up with food, and others can be pieced together by our own mortal organs,

    all those are essential upon fundamental mineral absorption, to so many metabolic processes, for some truly special nerve structures, neurotransmitters, even the entire non standard defense and immune system is shaped by them,
    whatever you may imagine,

    all backed by indispensable DNA molecules, planing those proteins and vitamins,
    and as well made from those bioactive compositions, delivering marvels,

    the obvious dissimilarity between natural bioactive and inert artificial vitamins and proteins,
    could be pictured as a key that enters a door lock, turns the lock, opening the door,

    while an artificial vitamin would exclusively be able to slide into the lock, but not to turn it,
    consequently blocking the door in fault of a jammed lock,

    rendering impossible normal biological procedures, 

    often shutting them down permanently,

    cheers

    milo

    (reply)
  52. Todd  October 20, 2013

    John U,
    Thank you for your reply, I will spend some time exploring that website.
    I have heard of glucogenisis but my impression was that elevated BG regardless of the source will trigger an insulin response. I have been endeavouring to modify my exercise and nutrition regime to minimize BG while maintaining a state of NK in order to eliminate arterial inflammation.
    I have reduced protein consumption considerably and replaced the calories with fat. This has had a very positive effect on my blood pressure and seems to be slowly modifying my body composition, notwithstanding my current weight plateau. However, I am concerned about the potential long term effects of an elevated BG level as the principle reason for me embarking on this journey was my elevated CACS score and my strong preference to avoid statins, which was the prescribed course of action of my physician.
    Once again, thank you for your response.

    (reply)
    • John U  October 29, 2013

      Hi Todd. I am no expert and in fact I am just slogging through all the info on nutrition and trying to follow along. I don’t know your history but I think that you are doing the right thing in following a high fat, LC diet . The blog to which I referred, Hyperlipid, is hosted by a man who eats about 80% saturated fat in his diet. Since the CAC score would reflect what has happened to your ateries over many years, I don’t believe that it would predict with any high degree of accuracy your outcome after you have modified you nutritional intake. From the reseach on CAC that I have seen, the evidence that CAC is a good predictor of CVD hinges on the subjects continuing for many years whatever they were doing in the past. What’s done is done, and maybe it cannot be reversed, but maybe some can after a diet change for the better, so I would not assign a high predictive ability to the cac score unless you know something more than I do.

      I also would not take the statins. There is already so much written in books and blogs about the poor research that was done in support of their use, and the evidence of seriously harmful side effects. You have made a smart choice.

  53. Rebecca  October 20, 2013

    I’m a recent uterine cancer survivor. The contributing factors to my cancer were these: over 50, post-menopausal, nulliparous, and overweight. All of these factors interact in ways that are complex and likely highly specific to an individual. I hope to not have a recurrence, and am regaining my stamina to increase my activity levels, as exercise is also preventative, according to the data.

    I wonder if the two instances in which I experienced sudden & dramatic weight loss — 40+ pounds in a matter of two months, had an impact on my developing cancer.

    The context for these weight loss episodes, once due to depression following a sexual assault, and again after a nasty divorce, with subsequent weight gain plus, has meant that I metabolized a lot of fat very quickly. Since abdominal fat is estrogenic in women, did these sudden weight loss episodes dump a lot of estrogen in my system, causing my endometrium to grow beyond a healthy amount? Was the time I had a more gradual weight loss, one that has since reversed, a less metabolically impactful process, or did that fat metabolizing also release extra estrogen into my system?

    The incredible levels of hatred directed particularly at women for being fat, or even larger that a size 6, is psychologically quite damaging, and well documented. I never want to diet again, yet I need to lose weight to maintain my cancer free status, after surgery & radiation. At age 58, have I so damaged my metabolic system by this weight roller coaster that I have no ability to lose and keep weight off?

    When the AMA declared obesity a disease, a stance that I think will do more harm than good, I asked my Dr. how my HMO was planning to rend to this. I want a biweekly support group for emotional eating, help with stress management, and a PT who can coach me at a gym three times a week, all paid for by my insurance. I have three weight related diseases; osteoarthritis in my knees, sleep apnea, and cancer. Yet all my usual health indicators are good: blood pressure, cholesterol, blood sugar, stress heart test.

    I am scared of a cancer recurrence or metastases, and I need medical support to help me correct a lifetime of emotional overeating & lack of exercise. I have not been able to do this myself, and work full time, manage a home, a marriage, raise kids, deal with aging parents, cope with not enough money, etc. It’s all just too damn much.

    (reply)
    • Peter Attia  October 21, 2013

      These are important questions, Rebecca, and I wish I knew the answers. Your last point really resonates and I’m sure others, too, will understand and relate to it. I look forward to the day when a community exists around support and sponsorship for helping us all get through these struggles.

    • Sofie  October 26, 2013

      On money & related, check out Mr Money Mustache, or some other financial independence blog. There’s probably a lot of things you’re spending money on that you’d be perfectly happy without.

  54. Mark3000  October 22, 2013

    Great stuff, Peter. The blog is awesome; this is the first time I’ve had a chance to comment. And I have to say that I’m super pumped about the thought of you and Tim Ferriss teaming up.

    You guys are both high on my list of “people I’d like to work with someday”. And, yes, I actually have that list. :)

    -mark

    (reply)
    • Peter Attia  October 22, 2013

      Ha ha, Mark. Last time Tim and I worked out together in SF a few people interrupted Tim to ask if he was Tim. He was very gracious and it was funny. I’m sure he gets it all the time.

  55. Karl  October 23, 2013

    Reporting age-adjusted mortality rates over all ages the way Dr. Abrissa does, when he claims that mortality “has decreased by only 5 percent since 1950″, tends to conceal greater relative reductions of mortality at younger ages, as noted by Kort 2009. We cannot know to what extent the younger birth cohorts also will experience lower cancer mortality at old age in the future: the great mortality reductions at very young ages are probably much due to specific treatment success in e.g. acute leukemia and testicular cancer, but this does not seem to explain the declining mortality among people in their 40s and 50s.

    (reply)
  56. Jared  October 23, 2013

    Hey Peter, I stumbled upon your talks on youtube in my own quest with a Keto diet and they were awesome. Thank you for yours, Gary’s and any others who are spreading these ideas that maybe we have got it all wrong, that maybe it is carbs that are killing us. I think the science is getting there and you guys are at the forefront of the battlefield in nutrition. That is a great thing to be apart of and much respect. Keep pushing and make sure your voices are heard as much and as loud as possible.

    As for cancer, even Sloan Kettering is coming up with carbs are huge factor in cancer.
    Watch the president of Sloan Kettering speak on it here. They are roughly the same type of presentation but I figured I would share both.
    2010 – http://youtu.be/WUlE1VHGA40
    2012 – http://youtu.be/PV3UnNvN3NI

    (reply)
    • Peter Attia  October 24, 2013

      Yes, Jared, many very influential oncologists, such as Craig Thompson (here) and Lew Cantley of Cornell are really beginning to view cancer as a metabolic disease, a view I obviously share.

  57. steve  October 24, 2013

    A blood glucose question: If one has increased BG when on lo carb, higher fat, say 90-100 reading vs 70′s to 80′s when on a much higher carb diet and lower in fat, would this be indicative of someone who is insulin sensitive? Assume Trgs no more than 60 in both cases.
    If one has lo Trgs 60 or less regardless of carb intake what does tt mean?

    Thanks,
    Steve

    (reply)
  58. Jeff  October 25, 2013

    Why should anyone reserve judgement on Tim Ferriss? He has a public persona and his business is literally selling himself, his worldview, and his techniques. To suggested anyone should reserve judgement on him because we have not met him is silly. The problem with Tim Ferriss is not that he is a self-help guru or or that his business is self-promotion. The problem is that he does this from the perspective of a sociopath and unapologeticly promotes the schemer mentality. I would have thought someone of your caliber would give little credence to Mr. Farriss.

    (reply)
  59. Roman  October 25, 2013

    Peter,
    I really enjoy your YouTube talks, you’re very well-spoken and fascinating to listen to.
    I wanted to ask you if glycine will spike insulin and push me out of ketosis at doses of 15g with every meal (4 meals/day). I’m using it to treat negative symptoms of schizophrenia because it’s supposed to increase nmda receptor activity. I couldn’t find an answer online to this so I’m asking you since youre the expert on ketosis. Weight loss/health and treating negative symptoms are both high priorities of mine, but I can always switch to sarcosine if glycine does spike insulin.

    (reply)
    • Peter Attia  October 26, 2013

      Probably, since glycine is a gluconeogenic AA (AA are typically gluconeogenic or ketogenic). But give it a shot.

  60. Andrew Logan  October 26, 2013

    I’m a bit bemused by the fairly vitriolic reactions to Timothy Ferriss. of course I have never met him, but to describe him as a sociopath is bizarre. I have his first two books, and am currently reading his latest, “the 4 hour chef”. The latter is the most enjoyable cookbook I have ever read but it’s a lot more than a cookbook. Based on my reading, he seems to be a truly independent thinker who is happy to share what he’s doing. For me, I would never have found the LCHF diet and ketosis if I hadn’t first read “the 4 hour body” so thank you Tim.

    (reply)
    • Peter Attia  October 26, 2013

      That guy’s comment was simply stunning and not even worthy of rebuke.

  61. KC  October 26, 2013

    Off topic.

    Big money starting to publicly acknowledge we are at a cross roads.

    http://www.youtube.com/watch?v=HMKbhbW-Y3c&list=PL0B44DF914C4FB3ED

    http://www.scribd.com/doc/178995229/CS-Sugar

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  62. Fritz Andersen  October 26, 2013

    Reading all the fascinating comments on this blog I would like to add an article I recently published in the Washington Post newspaper. MY ADVISE TO ALL OF YOU IS: do NOT GIVE UP ON YOUR RESEARCH AND FIND THE OUT OF THE BOX THINKERS, AS I DID FINDING the virus infusion therapy at Duke university which has so far controlled my GLIOBLASTOMA FOR OVER 2.5 years
    Regards Fritz Andersen, MDQ

    http://www.washingtonpost.com/national/health-science/surgery-radiation-and-chemo-didnt-stop-the-tumor-but-an-experimental-treatment-did/2013/09/23/1b8e8f92-0f4f-11e3-85b6-d27422650fd5_story.html

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    • BobK  October 28, 2013

      About T. Ferriss…..

      Dr P., Alexandra M, Curtis, Jeff, et al-

      I don’t know the guy, I don’t if Tim Ferriss & TImothy Ferris are the same guy. I don’t know the details of this brain supplement product or business. But it appears they might be the same person. http://en.wikipedia.org/wiki/Timothy_Ferriss

      That said, before I was introduced to his 4 Hour Body book I was dabbling in carb restriction ala Dr Mark Hyman (PBS infomercial fame) . Again, people can poo poo this guy too. BUT using Hyman’s techniques, then Ferriss’, then Primal Bluprint & finally PaleoDiet, I went from 200 to 190 (I’m 6′) … with ease & very little exercise. A year has gone since I started and there is no sign that the fat will return.

      I’m an older mechanical engineer who is used to unconventional solutions…. I constantly question conventional solutions, show me the results / data). I always look for “better”. I reflect on my processes.

      Before I was given a copy of 4 Hour Body, I was poking my finger MANY times per day to determine my own blood sugar response to all manner of foods & meals. Once I saw that Ferriss’ extensive data set mirrored mine, I gave my finger a rest. :)

      People can bash Mr. Ferriss but I have had great success with his techniques. His techniques are similar to Hyman, Sisson & Paleo, they all occupy the “overlapping space” of carb restriction. They differ somewhat in their detailed recommendations but they all work (for me). Maybe carb restriction is really more of an “energy matching” philosophy? That coupled with eating real food, not the over processed fare producted by food corps.

      I’m not sure what the perfectly correct model is…that’s for Dr. P & his associates to discover. I’m happy with the current results of my N=1 experiment. I fitter & stronger than I have been in 15 years and it’s relatively easy.

      The conventional wisdom of the last 60 years (lowfat, whole grains) did not not prevent my father or father-in-law from suffering death by cancer or heart disease. One was fat, the other “skinny fat”.

      I’ll take my chances with carb restriction.

      And now to address Jeff’s comments….
      >>He has a public persona and his business is literally selling himself, his worldview, and his techniques.<<>>..does this from the perspective of a sociopath and unapologeticly promotes the schemer mentality.<<<

      that's pretty generalized & unsupported comment…. show me the data / links?

      And btw…."Promotes the Schemer Mentality"… is that your original thought or did you lift it from
      http://dontstepinthepoop.com/get-rich-sociopath ?

  63. Warren Roberts  October 28, 2013

    Maybe the whole paradigm needs to shift.

    We share tumor growth on sugar over consumption with fruit flies. For creatures so far removed evolutionarily from each other to share the same “problem” says there’s some advantage to it.

    That says to me that maybe cancer is like sickle-cell disease — it normally provides an advantage, but sometimes it over-expresses and causes problems.

    Chronic sugar poisoning kills pretty quickly in the wild, but most cancers take months or years.

    Cancer cells use 200 times as much sugar as normal cells, so a little tumor may eat enough sugar to keep one alive until the sugar runs out. The common loss of appetite associated with cancer would help starve the tumors and limit the amount of sugar that has to be dealt with.

    If cancer is an evolutionarily-conserved protective mechanism against excess carbohydrate consumption then trying to short-circuit it without fixing the dietary problem is going to be very hard.

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  64. Marie Hasselberg  October 28, 2013

    Thanks for yet another great post :). After being slightly overweight for my whole life, I completely changed my diet this summer to low carb. I’m currently on very strict low carb and fluttering in and out of ketosis (I’m in ketosis during the week and fall out of it in the weekends due to wine drinking. Student life, eh?) I absolutely loving being in a ketogenic state! I used to be constantly thinking about food and couldn’t go more than 4 hours between meals. As I used to say: I lived to eat. Now I can skip one or even two meals without anywhere near the discomfort I used to have, my mood and energy levels are a lot more stable and I feel great! However, I’m not losing weight as fast I expected. I try to stay in ketosis, I eat when I’m hungry and eat till I’m full. After years of calorie counting, I find it hard to resist not to count, so I’m wondering: what happens to excess calories (from fat) when you eat low carb? Since the fat won’t elevate insulin levels, would any excess would just “pass through” the system?

    A couple of days ago I came across this article (http://www.bodyrecomposition.com/fat-loss/insulin-levels-and-fat-loss-qa.html) stating:

    “Contrary to popular belief (espoused by people still reading literature from the 1970?s), insulin is neither the only nor single most important hormone involved in fat storage. Rather, a little compound called acylation stimulation protein (ASP) has been described as “the most potent stimulator of fat storage in the fat cell”. And ASP levels can go up without an increase in insulin (although insulin plays a role).”

    The article is poorly written and lacks references, but still piqued my interest. I tried to read up on ASP myself, but what I found was a bit too technical for a layman like me. What are your thought on insulin vs ASP? Do you think you could do a post on the other hormones apart from insulin that affects lipolysis one day? Have you got any tips that might speed up my weight loss?

    Thanks again for sharing your knowledge and for writing this blog!

    (reply)
    • Peter Attia  October 28, 2013

      Marie, I’ve commented on ASP before. I have not seen any evidence suggesting ASP plays a greater role in the role of fat balance than insulin. You may find the fat flux post interesting.

  65. Amanda  October 28, 2013

    Hi Peter,

    I have previously told you about an episode on Australia’s science show Catalyst called ‘Toxic Sugar’ (in which Taubes/Lustig amongst others were interviewed). The same show has just (very controversially) aired part 1 of a similar show about cholesterol and saturated fat (Taubes interviewed again).

    Heart of the Matter part 1 – Dietary Villains: http://www.abc.net.au/catalyst/stories/3876219.htm

    Part 2 of the series airing in 2 days talks about statins. Which has caused more controversy:

    Professor urges ABC to pull Catalyst episode on cholesterol drugs, says it could result in deaths:
    http://www.abc.net.au/news/2013-10-28/professor-says-abc-catalyst-episode-could-result-in-deaths/5050866

    If anyone is interested the ‘Toxic Sugar’ episode can be found here: http://www.abc.net.au/catalyst/stories/3821440.htm

    Thanks,
    Amanda

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    • John U  October 29, 2013

      Amanda, thanks for sharing the links for the Catalyst series. These are great for sending to my friends who are not easily persuaded that “it has all been a big fat lie”.

    • Amanda  October 30, 2013

      You are welcome John. I’ll also post up links to part 2 if it airs as promised tomorrow.

      I’m not sure if you are Australian or not, but one of the reasons it is getting so much attention here is because the ABC is the government/taxpayer funded national broadcaster. So people seem to think they should only report on what the ‘establishment’ believes.

    • Amanda  October 31, 2013

      Catalyst – Heart of the Matter Part 2 – Cholesterol Drug War (aired 31 Oct 2013)
      http://www.abc.net.au/catalyst/stories/3881441.htm
      “The views expressed in this episode of Catalyst are not intended as medical advice. Please consult with your doctor regarding your medications.”

  66. Myddryn Ellis  October 29, 2013

    Hey Peter,

    Since fat suppresses HSL, is this effect large enough to warrant being cautious about eating “too much fat” or “too many calories from fat” ?

    (reply)
    • Peter Attia  October 30, 2013

      High fat intake plays a much larger role on the RE side of the equation, not the L side. So the effect of HSL is less important.

  67. Jeff  October 29, 2013

    Bob K.

    Re. Ferriss

    That website you link, your’re exactly right, and there is no shortage of other spot-on Ferriss critique in various blogs and one-star amazon reviews.

    Peter, please don’t misunderstand, I believe your blog is one of the best and most valuable on the internet; I can think of few more worthwhile non-profits than NuSci. But, re. Ferriss, there is nothing “stunning” about calling a spade a spade.

    (reply)
    • BobK  October 31, 2013

      Jeff October 29, 2013
      Re. Ferriss

      I was looking for you to produce real proof… just because someone is bashed or vilified on a website doesn’t make it true. I’m sure for every negative comment or characterization there are many more positives.
      I’m more focused on results…. not personality or character attacks.

      My “experience” with Tim Ferriss?
      My limited data set matches his. His techniques worked for me.
      He appears to be a self-promoter …. omg, unheard of behavior! oh, I guess not. :)

      Not my style but I cannot argue with the outcome.

      You appeared to parrot (plagiarize?) an insulting description …
      I was hoping for something more substantive….show me real data.

  68. Creanau  October 30, 2013

    Great blog here Peter, I’m glad to have discovered you after seeing your talk over on Ferriss’ blog. I’ve trawled through your FAQ and exercise/ketosis posts and have begun piecing together a plan to lose the last few kg of fat I have around my midsection.

    Thus far I’ve gleaned that removing grains, dairy and carb-laden foods is what get’s me 80% of the beneficial fat loss via ketosis. I also want to know how exercise, or whatever else, can play a role to get that remaining 20%. When you get a chance, please consider doing a prescriptive post for the more athletically inclined bunch that want an effective and efficient route to fat loss — perhaps, as the answer to the question: If you could go back in time to your chubby twenty-something athlete self, what would you have him do, from dawn to dusk, to lose the most bodyfat as quickly as possible?

    (reply)
    • Peter Attia  October 30, 2013

      Will give it a shot. I do have a planned post on some of my favorite exercises that one can do with body weight.

  69. Bryndís  October 30, 2013

    Dear Peter

    I have read a whole lot on your site and I think it is great. I am from Iceland and I came across your lecture about your nutritional journey on youtube. Since then I decided to try out this ketosis for myself.
    I have been doing it for two weeks now.

    I wanted to ask you about your opinion on carb-loading. Many people here in Iceland are on a low carb diet, but many others are following a low carb 20-30 grams for 6 days a week but then have one day where the load up on simple carbs to make the fat burning hormones spike and by that increase the fat burning and to not lose muscle.

    I exercise a lot and have been thinking about doing this but it seems so contradictory with the purpose of being on a ketogenic diet.

    I have seen many doctors recommend low carb/ketogenic diet but I have not seen any research about this carb loading day once in a week.

    If you have the time, can you tell me your view on this matter?

    Kind regards and keep up the good work :)

    Bryndís Steinunn

    (reply)
    • Peter Attia  October 30, 2013

      Bryndis, I’ve addressed this in other posts and comments.

  70. Janaki  October 31, 2013

    Dr Attia – What is your opinion about William Li’s Ted talk “Can we eat to starve cancer?” and the role of angiogenesis in cancer growth?

    (reply)
    • Peter Attia  October 31, 2013

      I have not seen this talk yet, but am pretty familiar with the anti-angiogenesis work. If you want to read a good book about it, I’d recommend “Dr. Folkman’s War.” Despite the promise of this idea it has, despite literally billions of dollars in research and development through to FDA approval, not lived up to the promise we had in the late 90′s.

  71. Russ  October 31, 2013

    Hi Peter,

    I am new to your website and blog. Thank you for all the great information, personal and profession, you provide to readers.

    I have been low carb/high fat for about a month now. At my heaviest, I was 250lbs and my height is 70 inches. I have lost about 20 lbs in the first three weeks with virtually no exercise. What is a reasonable amount of weight I should expect to lose month to month, given that I continue to lower my carbohydrate and protein, and increase fat?

    Thanks,
    Russ

    (reply)
    • Peter Attia  October 31, 2013

      Range of sustainable weight loss in most literature seems to be about 1 pound of fat per week, but can be higher (or lower). Initial weight loss is often accompanied by water loss.

    • Bobk  November 1, 2013

      Russ-
      Welcome to low carb eating!
      I’m about your size. A little over a year ago, I started at 220 and in ~ 7 months I got down to ~190.
      I’ve been more or less 190 since Jan 2013.
      I was a total newbie when I started but I’ve read a LOT. I used various low carb techniques in sequence & parallel.
      Mark Hyman – Blood Sugar Solution,
      Tim Ferriss – 4 Hour Body,
      Mark Sisson – Primal Blueprint,
      Paleo DIet

      My weight weight loss averaged about 1 pound a week BUT some weeks I lost nearly 3 pounds… sometimes I plateaued for a week or so. I did minimal exercise; walking & some minor self weight work.

      I also lost about 3 inches on my waist. Funny thing? My BMI at 25.8 still tags me as “overweight” despite the fact that most people who know me think I’m too thin! Personally I think the BMI model pretty much sucks, since two people of the same height & same weight have the same BMI. No consideration that one person might be ripped & the other a couch potato. The BMI model does not consider ‘body shape’ or body fat %.

      Here’s website that has an interesting calculator and also discusses waist to height ratio.
      http://home.fuse.net/clymer/bmi/
      By adding ones waist measurement to the mix, they at least attempt to consider ‘fat’ vs ‘muscle’. In the writing there is a link to a USAF thesis that examines the usefulness of waist to height ratio as a fitness predictor.

      As you lose weight consider recording your waist measurement. As you “recomp”, lose fat & gain muscle, the tape might be more useful than the scale.

  72. Peter  October 31, 2013

    Need help in the BM department, any suggestions for fiber supplements that will not kick me out of ketosis. The lowest I can find is sugar free Metamucil at 6 carbs which is big number when trying to stay under 20 – 25 per day. any magical, low carb super fibers out there?

    Love your approach, very inspiring.

    (reply)
    • Creanau  November 1, 2013

      Yes, raw organic carrots. Eat 1-2 a day and you’ll be good to go.

    • John Smith  November 7, 2013

      Avocados maybe? 1 cup would give you 10 grams of fiber and 12 grams of carbs.

    • Joshua  November 13, 2013

      Peter – I’ve had the same problems when going lower carb. I recommend raw potato starch. Most of the starch is “resistant starch” and indigestible by humans – it goes to the large intestine where it is digested by our microbiome. Do a search for “potato starch ketosis” – you should find some articles where people have personally experimented and verified that potato starch does not kick them out of ketosis.

      DO NOT COOK the starch.

  73. Doug  October 31, 2013

    Peter, I have to ask this. You noted in the thread that you are familiar with Thomas Seyfried’s work on cancer. One thing about his research is that he defines specific metabolic targets to effectively fight cancer: glucose 55-65 and ketones >5, combined with calorie restriction on a ketogenic diet (~20 kcal/kg ideal body wt). I also remember reading the experiment by George Cahill in your ketosis post where subjects were injected with insulin until glucose was <20 and their high levels of ketones kept them from experiencing severe hypoglycemic symptoms. Do you think glucose could be safely lowered even more than in Seyfried's work (even if not as low as 20), and do you think it would increase its effectiveness in fighting cancer?

    (reply)
    • Peter Attia  October 31, 2013

      Doug, good memory! Yes, Cahill showed repeatedly that humans could remain asymptomatic with glucose at 1 mM (less than 20 mg/dL) if BHB was north of about 5 mM. I can also speak to this from personal experience. However, to get that low requires insulin injections. Even in starvation — complete starvation — glucose rarely goes below about 3 to 3.5 mM. That said, I don’t think injecting insulin is an effective anti-cancer strategy, which is probably where Seyfried gets his range.

  74. Alison  October 31, 2013

    Hey Peter, great article. Now on the topic of cancer, have you heard the theory of that some forms of cancer may be caused by a Vitamin Deficiency. There has been this age old theory that the actual root cause to many forms of cancer have been a result of a Vitamin (Vitamin B17/ leatrile) that has been processed out of our diets and never fortified back in, thus creating these cancer cells. Of course, it has stirred up a lot of controversy over the years with the most prominent of pharmaceutical companies and the FDA calling it “quackery” and “poisonous”. Of course, I am not necessarily buying into these statements but I am curious to hear your thoughts on this. Of course like most doctors, I am sure you have probably never even heard of this Vitamin or these cancer claims, as they have been suppressed from the public with conscious effort.

    Here is a link to a book on Amazon called “A World without Cancer” that discusses the preceding paragraph in finer detail with scientific proof. If you click on this link you will find an overwhelming amount of positive reviews of people citing how “life saving” it was. I myself, have bought this book, and can admit that it is definitely enlightening and brings about the discreet corruption of the Cancer industry. It’s honestly unbelievable. There is also a phenomenal documentary about it on Youtube as well as doctors and cancer survivors making videos of this idea.
    http://www.amazon.com/World-Without-Cancer-Story-Vitamin/dp/0912986190/ref=sr_1_2?s=books&ie=UTF8&qid=1383262617&sr=1-2&keywords=a+world+without+cancer

    Of course this vitamin is illegal in the US, but here is a Hospital in Mexico called the Oasis of Hope that uses laetrile as one of their main treatments. Just look at the unbelievable survival rates: http://www.oasisofhope.com/patient-survival-statistics.php

    And here is a description of the treatments they used to achieve these results:
    http://www.oasisofhope.com/laetrile-therapy.php#amygdalin

    What do you think of this?

    (reply)
    • Peter Attia  November 1, 2013

      Alison, hard for me to believe. Certainly one of the most famous examples is Pauling’s insistence that vit C deficiency caused cancer. Given his status, this was given much credibility for a while until it seemed there was no evidence to support it. I don’t doubt what you say about the cancer “industry” but I have not seen compelling evidence of the vitamin hypothesis.

  75. steve  November 2, 2013

    OT, but I figured the people on this blog would be most likely to know the answer to this:

    I’d like to monitor my ketone levels regularly, and it sounds like the product most recommended for that is the Precision Xtra. But on Amazon the strips cost $5.69 each, which gets really expensive if you’re using 1-2 per day. Has anyone found a cheaper alternative?

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  76. Deleon  November 6, 2013

    Hemp is a very valuable plant, serving a number of mankind’s needs. It make superior rope, superior cloth as in canvas, and would be in production today if not for its famous quality of making one relaxed and forgetful. To keep the worker base alert and motivated to meet corporate goals, cannabis has been banned or regulated by most of human society. It is not just rope and cloth production that suffers. The very qualities that allow hemp to make one relaxed and forgetful have a positive effect on numerous diseases.

    Cannabis smokers get red eyes because circulation is improved. Nancy will relay that her swollen ankles and feet were cured by hemp seed, which is sky high in Omega-3 and Omega-6 oils. Her doctor is astonished that she does not need the elastic stockings that he prescribed for her when she flashes her trim ankles at him. How does hemp oil, which unlike hemp seed does contain THC, cure cancer and ease MS and glaucoma? Many diseases are caused by the body itself, a reaction to stress or depression. Ease that, and the body’s normal functions return.

    Cancer is a result of a failing immune system, most often due to a sense of helplessness, an inability to escape. This accounts for spontaneous remissions, where the cancer, even at the point of death, just turns around and shrinks out of sight. The person has decided to live. A stoned or even slightly stoned cancer patient forgets why he was depressed. He instead notices the birds singing, the smile and wink from a stranger passing by, and the short term memory loss cannabis is famous for allows him to see that life is worth living.

    MS is an auto-immune disease, where the body attacks and destroys its own cells. It is caused by a hyper-vigilant immune system, a reaction to stress. Relaxed by cannabis, and with a short term memory unable to even recall what the worries were, the MS patient finds their immune system reverting to normal. It is not just relaxation from muscle spams, it is in fact moving in the direction of a cure. This is the case for disease after disease, where the body has created the problem. The trend is thus for cannabis to become legal, else at least provided to sufferers.

    In the Aftertime, this plant will become a mainstay in survival communities, as well it ought. It is as prevalent as weeds, its alternate name, despite being illegal throughout much of the world. Unlike alcohol, which consumes sugar or corn or rye for its production, and thus takes food from starving mouths, cannabis is not a food crop. It asks nothing more than to be allowed to grow, and does not require special treatment in order to do so. Like many of the plants that mankind has found particular useful as medicine, cannabis was seeded here on Earth. Planted, for mankind’s benefit.

    (Zetatalk)

    (reply)
  77. Deleon  November 6, 2013

    ZetaTalk: Genetic Engineering
    written Oct 15, 2005
    ________________________________________
    Where is man going awry in his tinkering? First, as a base, man should realize that genetic engineering has already been done, by nature, during evolution. Some of the things man struggles with, some of his diseases, are in fact protections from other problems, genetically selected to be passed forward only because they were of benefit in prior ages. The ability to pack food around one’s middle in the form of fat, a buffer against starvation. This was of course balanced in the past by times of food shortage, the fat dropped. Man was not intended to be perpetually pudgy. High cholesterol or high blood pressure is an advantage when one has to fight a tiger or bear with naught but a knife or stone, or run like hell to escape. This was of course balanced in the past by a period of tranquility, unlike what modern man faces in his daily battles with tension in the work place, the figurative tiger never dispelled. Even diabetes, developing later in life by the chubby and inactive, has a genetically selected advantage. The ancestors of those who did not develop diabetes during times of plenty, when early man had naught to do but sit in the berry fields or by streams overflowing with fish, were easy prey for predators, as they gained weight endlessly, huge toads that could not waddle away. Diabetes, type II, resists an intake of sugar by the cells and forces the body to lose weight, at a horrific rate, then lifts when the human is again slim.

    (reply)
  78. John Smith  November 7, 2013

    This is not necessarily relevant to the above post, but as a avid 5k runner and nutrition/fitness enthusiast I highly enjoyed your post “How a low carb diet affected my athletic performance”. It was very cool to see your results as far as aerobic efficiency and have since been very motivated to eat as close to a ketogenic diet as possible the last year. As you know, VO2 max is a big factor in performance (especially in the 5k) and I am very interested to know if you have answered this question you posed yourself in that post regarding your drop in VO2 max:
    “is there a way to reap the benefits of keto-adaptation of on the aerobic side, without any of the anaerobic cap costs?”
    If so, i’d love to hear more. If you have not yet, I look forward to the day you post on this topic. Thank you for all of the wisdom you’ve passed on. I know by body appreciates it.

    (reply)
  79. Myddryn Ellis  November 7, 2013

    Hey Peter,

    Is it possible to defend whole grain pasta, all-bran cereal and porridge as being as good as fatty meats, vegetables, dairy, etc? I’m excluding any added sauces, milk, etc. for now. I used to enjoy moderate portions of pasta with Parmesan cheese and no sauce (I don’t like the sauce), but now I don’t eat it. The GI and insulin index of pasta (both white and brown) are both quite low, particularly if it is thicker and cooked al dente (due to gluten?). The satiety index of white pasta is actually very low compared to brown pasta, suggesting a higher “insulemic” load, and it’s why I made the distinction. This is as opposed to both white and brown rice, white bread, and other refined grain products, which all have high “insulemic” loads.

    Here is the data Im using, I put it into excel. Definitely have a look at it. It’s from Holt et al. and from my understanding it’s really one of the few studies done on insulin response to food? http://s8.postimg.org/a3xlkwgb9/insulin.png

    (reply)
    • Myddryn Ellis  November 7, 2013

      By one of the few studies I mean specifically with regards to insulin & satiety indices.

    • Joshua  November 13, 2013

      Do you really think that pasta needs to be defended? There are very few foods that are going to be have ill effects on every person who eats it. If it works for you, go for it. I’d say start with what you KNOW works for you, and then try adding different things like pasta. I’d guess that some human populations are better suited to grains at this point in time than others.

      One thing to search for on this site is where Peter talks about his wife – she can consume carbs with very few ill effects in comparison to Peter who tends to get more not thin when he eats the carbohydrates.

  80. Lu  November 11, 2013

    Just wanted to drop a note to thank you for your blog. I, like you, was around 160 in high school, but during college (Queen’s, incidentally), ballooned to 190. I then proceeded to gain more fat in law school, despite regular exercise and plenty of complex carbs.

    I’ve been attempting to lose weight and have been diligently reading LCHF literature. You blog is perhaps the most data-driven and intellectually satisfying of all the sites I’ve frequented.

    Thank you!

    (reply)
  81. Daren  November 11, 2013

    Peter,

    you said you were in the Seyfried “camp” on the basis of cancer; most excellent! I have become fascinated with the subject (first year medical student at Campbell University School of Osteopathic Medicine!) and have recently learned of Loran dwarfism. Are you familiar with this? I speculate as to whether the faulty GH receptors and, thus, decreased rises in insulin and glucose over their lifetime could be a reason for their seeming resistance to diabetes and cancer. Interesting stuff, and there are a few here in NC with me looking forward to joining NuSI in the fight in the coming decade.

    (reply)
    • Peter Attia  November 12, 2013

      Yes, familiar with this.

  82. Al  November 20, 2013

    Peter: first, my apologies for being off-topic – I’m a bit freaked and am looking for some pointers to information that may calm me down. I had my first physical in years 2 days ago and my labs just came back great on lipids but with 110 fasting glucose and 5.8 A1C (estimated average glucose 120). The reason this freaked me out is that I’m pretty constantly very lo-carb (no bread, no cereals, no sodas, no sugar, a bit of fruit – chocolate, ice cream and alcohol on rare cheat binges on holidays etc.) and very high fat (bacon and egg breakfasts, cook with real lard, make my own biltong, whole milk dairy all around) in my diet so I’d have expected a lecture on lipids, not sugar! I’m also an occassional dabbler in intermittent fasting (I sometimes go a few weeks with no meals between 10pm and 1pm the next day) when I want to lean out a bit or just to cope with getting the kids off to school on time. I have this vague feeling that you may have addressed this at some point – that fasting sugars can appear (or are?) elevated on a low-carb / IF type diet but that this is to be expected and not cause for concern? If so, could you, or one of your helpful fans on these forums, please point me to that article? I’ve tried searching the site but with no luck so far. Also, do you think its worth asking for a glucose tolerance test to be sure that this isn’t a “real” problem with insulin resistance rather than whatever happens to fasting glucose on this type of diet? THANK YOU!

    (reply)
    • Peter Attia  November 20, 2013

      Hard to say, Al, without doing some detective work. I’m assuming this is an increase from your previous A1C, or you would not be freaked out, right?

    • Al  November 21, 2013

      Sadly, yes, the readings are worse now than they were 3.5 years ago when I was over 30 pounds heavier, eating lots of whole grains and fruit on the advice of a workplace nutritional counsellor, and had miserable HDL numbers (38). I went LCHF to drop the weight and rebounded on the HDL quite dramatically (49) but I have noticed fasting glucose creep up over time (I bought a precision Xtra reader but never got around to measuring ketones) especially since I got into IF. I had a routine to lift weights before lunch and found that if I’d had even a reasonably sized breakfast the workout would trigger reflux so the idea of skipping breakfast entirely seemed logical, especially if it would (apparently) stimulate fat burning in the process. I have appeared leaner when doing IF but the amount of glucose coursing around, particularly in the mornings, has me concerned. This morning a self-test also came back 116, had 2 eggs for breakfast and retested 90 minutes later at work and it was 121! (so much for morning cortisol!). I asked the doctor that ordered the tests whether he’d rather have me do a glucose tolerance test or a repeat of the fasting glucose and he opted for a repeat of the fasting glucose. I think I’m going to start exercising again (been off for 2 months due to an injury and work travel) and eating breakfast regularly before going in again but wondering if there is anything else I could be doing to get to a better fastng glucose number. We have a 10 month old that is a frequent source of sleep disruption but I’m not sure that a 20-30 point jump in fasting glucose can be ascribed to sleeping patterns, can it? The only other thing I can think of is coffee… I drink a lot of it (6-8 cups most days), sometimes with cream, butter and coconut oil, often black. Could this be messing with overnight insulin response?

    • Peter Attia  November 21, 2013

      Certainly possible. See what happens when you stop that.

    • Anne  December 8, 2013

      Hi Al

      My husband and I have both experienced increased fasting blood glucose levels since going on a high fat low carb diet almost 12 months ago. I’ve tried researching why but haven’t had a lot of success with a clear answer. The link below is the clearest explanation that I could find. We want to stay on this way of eating and I hope it isn’t causing any additional health problems.

      http://thepaleodietitian.com/2012/02/14/paleo-diets-lead-to-higher-fasting-blood-sugars/

      Regards
      Anne

    • XO2062  January 24, 2014

      Hi Al,
      there might be no reason to worry about the glucose level you have. Nowdays there might be less than one out of 1000 who is doing a kind of low carb/ketogenic diet and there is no valuable statistics availabel at all. Dr. JAN KWANIEWSKI in Poland has adviced his patients to use optimum nutrient for more than 40 years to cure all kinds of deseases. In his book, “Optimal Nutrition” ,translated from Polish, (I read the German one), he indicated that those who do optimum nutrition (carbo intake less than 40g per day) use to have glucose level of 110-140mg% and most conventional doctors then get alert and the patients get concerned as this used to be an indication of diabetes!
      JAN didn´t deliver an explanation. But given the facts that he has had extensive expereiences and the lack of valid statistics I reckon that he might be right. After all, there has been over hunderts of thousands who have benefited from his optimal nutrition …

  83. Donald Vega  November 21, 2013

    Hi Peter,

    Great work!

    I’m a doctor in Nutrition nad Corrective Exercise Specialist from Costa Rica and to my knowledge, the only one here teaching “out side the box” nutrition and have been doing that for 9 years now plus 6 more years in the Corrective Exercise domain.

    I study no less than two hours every day and a few months ago I crashed into your website where I found the explanation for a theory that I had in my mind while working with triathletes. I was sure that there definetely had to be a way that an endurance athlete could access their fat as energy during competition instead of just glucose. Of course, ketone bodies were taught in nutrition school only as an undesireable effect of a diabetic state and not as you clearly explain them in your blog (my god, thank you for that!).

    To make a long story short, I have found in your work a very scientific, yet, practical approach to nutrition and consider you a real teacher for me and would love to study more from you apart form the material presented here (I’m in the process of devouring all your blog).

    Do you have a training system or can take someone for a week or two to learn from you?

    Thank you and keep up the good work!

    (reply)
    • Peter Attia  November 21, 2013

      I don’t, Donald. But there are lots of great resources out there.

  84. Demetrius  December 19, 2013

    Peter,

    Saw this article on my R&D newsletter, thought you might be interested in looking at it further. Looks like sugar is a pretty good culprit for increasing the chances of certain types of cancer.

    Role of sugar uptake in breast cancer revealed
    http://www.rdmag.com/news/2013/12/role-sugar-uptake-breast-cancer-revealed?et_cid=3668296&et_rid=54724808&location=top

    “A dramatic increase in sugar uptake could be a cause of oncogenesis… we have discovered two new pathways through which increased uptake of glucose could itself activate other oncogenic pathways….

    “We found that overexpression of GLUT3 in the non-malignant human breast cells activated known oncogenic signaling pathways and led to the loss of tissue polarity and the onset of cancerous growth,” Bissell says. “Conversely, the reduction of GLUT3 in the malignant cells led to a phenotypic reversion, in which the oncogenic signaling pathways were suppressed and the cells behaved as if they were non-malignant even though they still contained the malignant genome.”

    (reply)
    • Peter Attia  December 20, 2013

      I’m working on my cancer post for Tim’s blog right now and this feeds right into it…
      Thanks for pointing this out for others who are interested.

  85. Jim Olsen  January 3, 2014

    Have you read Dr. Seyfried’s book Cancer as a Metabolic Disease? From the reviews by other MDs he recommends a ketogenic diet. This would seem to be something of interest to you and your readers. It would be great if you would comment on this book.

    (reply)
  86. William W  January 30, 2014

    Processes are unique but principles of how they work are much wider in application. Oxidative stress is listed as one of many sources of stresses when in fact it is the underlying reason for the effects of almost all the rest. Because oxidative stress is the chemical interaction both normal and induced from other stresses.

    For the bit where it seems they will never find the end or the start of it reminds of
    “Even time indefinite he has put in their heart, that mankind may never find out the work that the true God has made from the start to the finish.”—Ecclesiastes 3:11.

    Here is a much longer comment on Tim’s blog page
    http://www.fourhourworkweek.com/blog/2014/01/28/cancer-treatment/#comment-256505

    (reply)
  87. paula  May 4, 2014

    http://www.healthtruthrevealed.com/articles/1150/article

    Cancer Survivor Jerry Brunetti Attributes Healing To Nutritional Principles of the Weston A. Price Foundation
    INTERVIEWER: Pam Killeen October 6, 2006

    I love this interview. Jerry Brunetti is still going strong today. He’s very down on sugar (his expertise is natural remedies for soil, cattle issues, etc. The Mennonites have him come speak to them – he had to use his nature/animal knowledge on himself. Here’s just part of the interview which agrees with Peter’s analysis in so many ways:

    Jerry: In 1999, I was diagnosed with an aggressive form of Non-Hodgkins lymphoma (follicular cell). Based upon the tumor size found in my abdominal cavity, I was advised that, if I didn’t take aggressive chemotherapy, I was looking at 6 months to 2 years of life left. When I checked out the details associated with that, I found out that the survivability rates with this treatment were 35% within 5 years. I wasn’t given very good odds. I researched the MSDS and PDR to find out the side effects of the chemo agents the doctors wanted to use. Needless to say, after I reviewed the research, I declined mainstream medical treatment. The chemotherapy treatment mainstream medicine offered was called, ‘M.O.P’ and ‘C.H.O.P.’ Their approach was destructive to bone marrow, kidney and liver. My quality of life would have been pretty dismal had I chosen their protocol. I decided that they didn’t give me much of a chance. I wasn’t very excited about taking products that were cytotoxic (creating a lot of collateral damage to my own healthy tissues). In order to solve the problem, I chose my own protocols. I began searching for answers by finding out where the cancer came from in the first place. I started studying cell gene defects. The cell that has gene defects is what causes the malignancy to really take off. There are genes that are called ‘tumor
    suppressor genes’ and there are cells that are activating the carcinoma. Many things can cause cancer: environmental toxins, stress and something I call ‘western malnutrition’ (not eating enough of the right things such as the different types of good fats, amino acids, trace elements, macro elements and eating the
    wrong kinds of foods such as the bad fats, and sugar). Sugar is one of the main things that can predispose people to cancer. If they do get cancer, sugar really increases their susceptibility from dying from cancer because cancer is a ‘sugar junkie’. We’re consuming about 170 pounds of sugar per capita per year here in
    the United States. In the early 1800’s, we consumed about 10 pounds and sugar consumption translates into insulin production. Insulin is associated with inflammatory processes. All of the drugs, COX-2 inhibitors like Celebrex, Vioxx, are all predicated on the fact that we have so many inflammatory conditions today. Inflammation is coming from a deficiency in the long chain fatty acids (EPA, DHA), an excessive amount of the omega- 6 fatty acids (which are proinflammatory) and a high amount of refined carbohydrates and sugar consumption. When people consume an excess amount of bad fats, a deficiency of good fats and lots of sugar, doctors write a lot of prescriptions for Vioxx.

    Pam: Why did you avoid chemotherapy and radiation?

    Jerry: Neither chemotherapy nor radiation can cure cancer. That’s admitted by the National Cancer Institute the National Institutes of Health. In Fortune magazine, March 29, 2004, there was an article illustrating that survivability rates with people who have had metastatic cancer (where cancer spreads from the primary tumor to distant organs) has not at all improved over the last 30 years. That means that we’ve seen no improvement with the four major killers (breast, prostate, lung, and colorectal cancer). Over 200 billion dollars have been spent on cancer research. There have been 1.56 million published papers on cancer and 64 billion dollars spent annually to treat people with cancer.

    Pam: Cancer is a huge industry yet mainstream medicine is not making much headway in finding the cure. People need to start asking more questions, just like you did, Jerry. You initiated your own health campaign after you started doubting the efficacy of mainstream medicine.

    Jerry: The reports tell people that tumors don’t kill cancer patients; rather, metastatic illness kills cancer patients. Metastatic cancer spreads to the liver, brain, bones or other vital organs. That’s what kills people with cancer. In order to contain metastasis, you have to have immunity. A strong immune system is the
    only ‘drug’ that works against cancer. By the time a tumor is discovered there’s at least a billion malignancies in that tumor and they’re rapidly dividing – they’ve already ‘seeded’ the rest of the body by the time you’ve discovered you have cancer. In other words, you’ve got cancer seeds all over the body. What
    determines the survival rate of cancer patients has to do with whether or not the immune system is still operating effectively.

    Pam: Can you explain how the immune system works?

    ETC?

    (reply)
  88. Joshua Session  June 28, 2014

    Have you heard about the new research on how the immune system can regenerate after fasting? Also, have you heard about fasting as being a cure for cancer.

    (reply)

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