Ketosis in a Nutshell – Part 6, A Hungry Man

weighing-scales

(When all else fails, read the instructions.)

A hungry man finds a haven – what was it?

He was a very hungry man.

That’s what worried him. That, and the weight gain.

“he had a pathological fear of hunger” *

“I was literally afraid of dieting. I was afraid of being hungry.”**

A bean pole in high school, when he graduated he “was 6 feet tall and weighed only 135 pounds”. But that didn’t last. “At college I became the biggest eater on campus.”

He went to medical school and then came a residency in cardiology. “I had the reputation of being the biggest chow-hound in the hospital.”  He gained weight over the years, but his mind failed to register this, as he still had a mental image of himself as slim.  Perhaps he also partly didn’t want to recognize it because he was so afraid of the hunger that is a routine part of low-calorie dieting.

It took seeing a photo of himself for Dr. Atkins to recognize the fact that he had become  “a fat man“, as he put it – in the typically kind way people have when they speak to themselves about their weight.  The year was 1963, and Dr. Atkins embarked on a quest.  Not willing to face the hunger of the usual calorie restricted approach, he “was looking for “The Hungry Man’s Diet.””. He hit the medical research to look for another way. Kids – this meant picking up and reading ink-on-paper “medical journals” that sat on shelves in the “library” of the hospital.

What was it that he found?

And why should we think about this now, 40 years later?

Why should we care what Dr. Atkins was reading or thinking in 1963, almost 50 years ago?  Why should it matter now what he put in his 1972 book?  After all, he published a number of books after that one. No-one should be held to what their medical ideas were 40 years ago – new information and experiences bring rapid changes in all areas of medicine.

Well, it’s not like things are going so good on the weight loss topic right now. I thought I’d have a read of his 1972 book. I have a paperback version of that book, published in 1973 by Bantam. What I read in that book grabbed my attention. For example, “The result of fifty years of prescribing a so-called “balanced diet” for patients who actually were suffering from a metabolic imbalance is a raging epidemic of over-weight.” (p.2).  If you look at a chart of changes in BMI over the past decades, you will see that 1972 is now considered to be “the good old days” when it comes to the battle of the bulge.

When all else fails, read the instructions.

The vast majority of people do very well with following a low carb, high fat eating plan that is well thought-out and explained – such as can be found in The Art and Science of Low Carbohydrate Living. For most people, there is no need to make it more complex. Some people follow the instructions closely, and yet don’t find that their weight reduces into the normal range. Different people need different solutions. Can we get some ideas by looking back to the original version of the most famous low carb plan.

What was at the core of Dr. Atkins’ “Revolution”?

(Terminology – will open in new window)

There is a common perception to think about the Atkins Diet in terms of the protein and the salads and the low carbs. What does his first book tell us about what he was thinking?

In his book “Dr. Atkins Diet Revolution”, published in 1972, he describes the research findings and line of thinking that led him towards his approach to obesity. I looked into some of the research he discusses and found it such a fascinating insight into the medical thinking of the time that I have included a discussion of that below. I think if you click on the links to the abstracts and papers you will enjoy the read.

In summary, researchers had found that hunger was suppressed after 1-2 days of total fasting, and that this reduction in hunger was correlated to an increase in blood levels of ketones. Other researchers found that this also happened on a very low carbohydrate diet – within 1-2 days hunger was “absent” (maybe a bit of an overstatement) and blood ketone levels had risen over that time period  Diet trials with patients eating to appetite of unlimited protein foods and fats, with very limited carbohydrates, showed weight loss with lack of hunger.

Dr. Atkins was ready to try this approach for himself. Dr. Walter Lyons Bloom had developed a 3-day food plan to test the low-carb theory. People ate eggs, bacon, meat and salad. Dr. Bloom reported that they developed the same lack of hunger as was noted when patients underwent total fasting. Dr. Atkins tried it and had the result he was after. He was loosing weight and not hungry. Now, what about the ketones? In the publications he had read, when ketones were tested they used blood ketone testing.  Dr. Atkins bought urine ketone test strips at a local pharmacy. He tested his urine and there was the purple color on the test strip showing that he was in ketosis.

Slowly he developed this 3-day sketch of a diet plan into a workable long-term plan that enabled a gradual return to a higher level of carbohydrate intake, according to individual tolerance.

** The above information and quotes are from chapter 3 of the 1972 book “Dr. Atkins’ Diet Revolution”, entitled “How I Arrived at This Diet Revolution”.

Let’s look at chapter 2, entitled “The Diet Revolution: It Will Change Your Life”.

“This is the diet revolution: the new chemical situation in which ketones are being thrown off – and so are those unwanted pounds, all without hunger.”

“I have arrived at the conclusion that ketosis is a state devoutly to be desired, because while you are in this happy state … your fat is being burned off with the maximum efficiency and minimum deprivation (since in ketosis your hunger disappears!).”

“Here’s how this diet is significantly different. During the first week on this diet, you cut your intake of carbohydrates down to what is biologically zero. This creates a unique chemical situation in the body, the one most favourable to the fastest possible burning of your body’s stored fat. Ketones are excreted, and hunger disappears.” (Here he was comparing his program to several diet programs of the day that reduced carbohydrates, but not to less than 60 grams per day, thus not creating significant ketosis in most people.)

“We must maintain this chemical situation if you’re to continue to lose without hunger.”

Let’s look at chapter 5, entitled “If You’re Always Fat, Chances are You’re “Allergic” to Carbohydrates”.

“It is not a true allergy as we doctors know it, but it is a sensitivity to carbohydrates in the diet, which results in an overproduction of insulin (hyperinsulinism).”

“For millions who suffer the endless physical and emotional miseries of being fat, it is a tragedy that so few authorities understand most overweight for what it is – a disordered carbohydrate metabolism, which affects some people and not others, that is quite apart from the amount of food, or calories, consumed.”

The rest of this chapter focuses on the many effects of a disordered carbohydrate metabolism, including high insulin, diabetes and aspects of what we now think of as metabolic syndrome.

You can read most of chapter 1 online. The first 6 pages of the 8 and a bit pages of chapter one are included in an Amazon preview. This preview is labeled as from 1981, but it is identical to the Bantam 1973 paperback version of the 1972 hard cover version that I have. Since this is on the Amazon site, this review might not still be there when you try the link. LINK

Carb Control for Health and Appetite, Ketosis for Hunger Control in Weight Loss?

As far as I can see from a careful reading of his book and from the papers he cites as influences, in 1972 Dr. Atkins saw his contribution as having been the development of a program that (1) targeted ketosis as a sustainable tool in weight loss, (2) made ketosis workable long term to last throughout the weight loss period and (3) offered a workable transition to a highly individualised flexible controlled carb lifestyle for long term health benefits. He refers to the fact that a number of popular books advocating low carb intake had been published by 1972, but none of them (according to his report, I don’t have copies of these books) presented ketosis as a unique aid to weight loss – by reducing appetite and allowing maximum fat burning – much less presenting a workable long-term way to achieve this. He stated that his goal was to find a way to lose weight without being tormented by hunger and he found it – ketosis.  He also understood the need to avoid the many harms from carbohydrate intolerance – by a lifelong practice of keeping carb intake within one’s personal tolerance limits.

In the 1972 book, Dr. Atkins advocated deliberately maintaining a state of nutritional ketosis until the last phase of the weight loss period. When the person is close to their goal weight, they were advised to slow the rate of weight loss by further increasing their carb intake – and thus the ketones in the urine would slowly fade away. He noted that for some people ketones don’t show in the urine, in which case they will have to rely on symptoms – are they hungry, having cravings, not feeling as well or no longer loosing weight/inches.

From that point on (once the weight was at goal), he emphasized that it was vital to maintain health and weight control by continuing to carefully control carb intake. He advised that it was fundamental to long term success to make the effort to adjust one’s carb intake – both amount and specific foods chosen – according to one’s individual tolerance. It was important to carefully monitor oneself over time for weight regain or signs of carb intolerance. This tolerance level might also change over time.

Regarding carbohydrate intake (amount and food sources) over the long term: “You’ll end up with a diet that’s as personal to you as a pair of contact lenses.” (p. 29)

During weight loss: “You will find which shade of purple correlates best with your own feeling, and this, for you, is the ideal.” (p. 130)

What about the role of protein intake when aiming for ketosis?

Unfortunately, there is no reference that I can find in the 1972 book to the potential role of moderate or high protein intake as something that might interfere with the development of ketosis. Dr. Atkins writes that protein can be metabolised to glucose, but he doesn’t mention trying a lower protein intake (1) as a means to achieve ketosis for those whose urine test strips don’t turn colour or (2) as a means to enable weight loss for those whose weight loss is slow or stalled.

In the 2002 edition of his book “Dr. Atkins New Diet Revolution”, there is brief mention of the fact that too much protein can interfere with weight loss, but there is no focus on that.  For example, in Chapter 15 “Engine Stalled? How to Get Past a Plateau”, among the many suggestions given, there is no discussion of considering or lowering protein intake.

Chapter 20 “Metabolic Resistance: Causes and Solutions” is described this way: “This chapter is about extreme difficulty in losing weight … “. Adjusting protein intake is not discussed directly as a strategy, except in terms of the Fat Fast, which is one of many topics in this chapter. If the Fat Fast is successful and the Induction program is not, then Dr. Atkins suggests trying to adapt the Fat Fast, such as “simply follow the concept of increasing the ratio of fat to protein”.

In Chapter 17 “Lifetime Maintenance”, there is a statement and answer section.  One is “4. Misconception: You can eat any food so long as you do not exceed 20 grams of carbs a day.” The answer “Reality: If you eat junk foods or other nutrient-deficient carbohydrate foods instead of vegetables and other nutrient dense foods, you will miss most of the benefits I write about …”. No mention of amount of protein foods.

Yet, in the same section is Misconception #9, to which part of the answer is “Moreover, excess protein converts to glucose and can keep fat from becoming the primary fuel.” Brief statements similar to this are in 3 – 4 other places in the book, but never elaborated on. It seems from all this that Dr. Atkins dealt with this problem in the office, but that it just somehow didn’t make it into the book in a very clear way or with a description of how to tackle it.

Still, the vast majority of people can benefit greatly from a low carb diet, in the manner that Dr. Atkins taught, without needing to deliberately limit their protein intake – as long as they are following his instruction to eat as much food as required to feel satisfied, but no more.

Is there any difference in how to get into ketosis?

There are some differences here that are interesting to think about.

The first week is far more strict than what is now considered to be the “Induction” eating plan. The only carb sources allowed other than the small amounts present in flesh food, eggs and small amounts in such things as bullion, gelatin and spices were:

  1. hard, aged cheese up to 4 ounces a day
  2. heavy cream up to 4 teaspoons per day
  3. juice of one lemon or lime per day
  4. “two small salads a day (each less than one cupful, loosely packed) made only of leafy greens, celery, or cucumbers and radishes. …  Or else a sour pickle in place of a salad.”

In the second week, 5 – 8 grams of carbs are added to the daily diet, but this was the “old” way of counting the carbs, before Dr Atkins switched to subtracting the fiber content from the carb total, so serving sizes of vegetables were much smaller than now. That is, the serving amount of a vegetable that was said to give 5 grams of carbohydrate would actually contain much less “usable” carbs (sugars or starch) than 5 grams, because some of what was counted as “carbs” was fiber. Depending on what a person was choosing to eat, many would still be under the 20 grams of carbs (total carbs minus fiber) considered Induction Level now.

Thus, there would be a tendency for people to move into ketosis both faster and deeper in the first week, compared to the instructions from 1992 on, when “Dr. Atkins’ New Diet Revolution” was first published – which moved to a two week Induction period with less strict carb reduction. They would move into “week two” at a higher level of ketones than now and likely progress further into ketosis while following the “week two” instructions. For many people, depending on individual food choices, they would not be up to the carb intake of what is now the “Induction” phase until they reached week 3 and added another 5 – 8 grams of total carbs (total = fiber included in the count).

In fact, although it was called “week 2″, Dr. Atkins did not want to see anyone progress from the first week’s eating instructions until they were clearly displaying the symptoms and changes that suggested they were well into a state of ketosis. As well, of course, he expected to see the urine ketone test strips turn purple. “Now it is time to evaluate whether or not you may progress to level two.”  His criteria for moving up a stage in carb intake included such things as lack of hunger, correction of evening/night eating, sense of having more energy and losing weight/inches.

The week one instructions also could be used as recovery strategy to get back on track if one had any symptoms that too many carbs had been consumed – such as hunger or cravings. Again, these instructions would promote a faster move into a deeper level of ketosis that the later “Induction Phase” instructions.

Interestingly, when you look at the “Induction Phase” instructions in the 2002 edition of “Dr. Atkins’ New Diet Revolution” the daily intake of vegetables is limited to “approximately three cups – loosely packed – of salad, or two cups of salad plus one cup of other vegetables (see list …)”. Some higher carb foods, such as limited amounts of sour cream, avocado and tomato are allowed, but Dr. Atkins denotes these as “Special Category” foods and notes that they might need to be avoided if progress is not good. I think many people think of Induction Phase as including a lot more vegetables than that.

In Sum

Dr. Atkins’ 1972 book is the first presentation of a sustainable dietary program that deliberately overtly includes nutritional ketosis in a central role. In Dr. Atkins’ original presentation of his concepts, there was a dual emphasis on ketosis as the key to hunger control and fat mobilization during weight loss; along with carb control to individual tolerance as a key to health, to abstinence from trigger foods and to weight maintenance over time. There was an emphasis on a rapid transition into ketosis. There was an emphasis on targeting the degree of ketosis according to whether it met the duel main criteria of suppressed appetite with a sense of well-being. There was a strong emphasis on sustaining such a symptom-targeted state of ketosis until the weight loss phase was almost completed.

The vast majority of people do well with the instructions in low carb or low carb high fat (LCHF) currently recommended by responsible authors and bloggers. Still, there are those whose health goals are not achieved by following such instructions.  It may be worth considering aspects of other versions a low carb high fat approach. This has been a look back at history to review the roots of the current low carb lifestyle.

I found my journey into this book fascinating. This discussion focused on the ketosis aspect of it, but if you have or can access a copy of this book and you have a strong interest in the topic of low carb nutrition, you might enjoy reading this book as much as I have.

- – - – - – - – - – - – -

I’m doing my best to understand Dr. Atkins’ practice and thinking based on his books.  Because of a realistic need to keep things somewhat simplified in a book, there is likely a lot of Dr. Atkins’ insights and accumulated wisdom that didn’t appear in any of his books. There are a number of clinicians who have direct experience with Dr. Atkins who could provide much better history and insight – for example, Jacqueline A. Eberstein R.N. and Eric Westman M.D. It is Dr. Atkins’ books, however, that created the public perception about his work. Much of what is now called “Atkins” is a mis-interpretation or mis-representation of what people read, or half-remembered that they read, or thought they heard from a friend about what the friend read – - in his books.

* written by Jacqueline A. Eberstein, R.N., in her “Chapter 20: Thirty Years of Clinical Practice with Dr. Robert Atkins: Knowledge Gained”, included in the book “The Art and Science of Low Carbohydrate Living” by Jeff S. Volek, Ph.D., R.D. and Stephen D. Phinney, M.D., Ph.D.

- – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - -

More on the research that Dr. Atkins credited with informing his thinking about hunger, diet and obesity:

One line of thinking was to mimic starvation.

(Note that this is similar to how the ketogenic diet for epilepsy was developed, where they were trying as closely as possible to mimic starvation without the person starving.)

Fortunately, Dr. Atkins would not have had to look very far to find his first clues. In the July 28, 1962 edition of The Journal of The American Medical Association (JAMA, one of the most prominent medical journals in the world) there was a paper by Dr. Garfield Duncan and others.

“Correction and Control of Intractable Obesity: Practical Application of Intermittent Periods of Fasting” JAMA  1962;181(4):309312   abstract

They reported on their results with periods of total fasting (“non-nutritious liquids” and vitamins) lasting 4 to 14 days (in hospital) with 50 patients, and subsequent follow-up management.  The weight loss results were very good, but what caught Dr. Atkins’ attention was the fact that these patients did not experience undue hunger after the first 1-2 days.

“Anorexia was the rule after the first day of fasting” … that was interesting! (anorexia means lack of appetite)

Furthermore, “and paralleled the degree of hyperketonemia”.  In other words, hunger went down as blood ketone levels rose. It took about a day for the blood ketones to rise much.

Even more, “A sense of well-being was associated with the fast.”

Dr. Duncan was a very prominent diabetes specialist, with a strong interest in weight loss.(I see there is a Garfield Duncan Building at Pennsylvania Hospital). I found this interesting report about the work of Dr. Duncan – note that this report has to be viewed with some caution, as it apparently quotes a Reader’s Digest article from 1968, rather than a medical paper.

The other thing that really strikes me about this is that here was Dr. Duncan, a noted diabetes specialist, completely unafraid of the ketosis induced by the fasting. It is very regrettable that this correct understanding of diet-induced ketosis did not become common knowledge in the medical community.

There was also this article published in 1963 in The Transactions of The American Clinical and Climatological Association, 1963; 74:121-129.  LINK to full text.

“Intermittent Fasts in the Correction and Control of Intractable Obesity”

This paper reports Dr. Duncan’s experiences with now 107 “obese diabetic and non-diabetic patients”.  It is fascinating to read the full article and I encourage you to do so.  One interesting tid bit is that “in three cases of previously resistant psoriasis this disorder subsided during the reduction program”. (We keep re-inventing the wheel.)

The patients would be hospitalized for the initial fasting period, then sent home on a limited calorie diet (that was not low in carbohydrates).  At home, they would fast for 1-2 days at intervals, generally one day per week (patient examples given). Exercise was not permitted on fasting days.  Some information on the longer term is given, but it is limited in detail. Forty percent of patients regained to previous weight or more, 43% maintained their weight and 17% were still loosing at last follow-up, which was at 1 – 32 months. (This is not nearly an adequate look at the medium and long term outcomes.)

His conclusions include “The anorexia during total abstinence from food is associated with, and is believed to be due to, the hyperketonemia provoked by the fast.”.

Keep scrolling down the paper to the discussion among a number of doctors at the end, including other illuminating comments by Dr. Duncan, such as “once patients have been subjected to a total fast, invariably they prefer it to low calorie diets” – commenting on the one day weekly fasting program. They also discuss initial water weight loss and water weight regain with return to eating.

(That people preferred one day a week fasting to the daily miseries of a chronic low calorie diet hardly constitutes much of an advertisement for intermittent fasting.  It is more a comment on the limited options these people felt they had. Also, we don’t know if it would have been as useful without the initial period of strong ketosis. As well, truly long term results are not given. Finally, some people might move towards dis-ordered eating and restrict/rebound eating patterns in response to intermittent fasting.)

Dr. Duncan followed these papers with a number of other publications on this topic, until he retired in 1969, including looking at hazards of fasting and the use of allopurinol for high uric acid levels induced by fasting.

Dr Atkins also credits an influence from the work of Kekwick and Pawan, who published a number of papers on obesity in the 1950s and up to 1969.  What he understood from their work was that ketones also appeared in the urine after 48 hours without carbohydrates in the diet – thus you could have ketosis without fasting -  and the ketones were again associated with loss of hunger. The loss of hunger was interpreted to be because the body was satisfying its hunger by burning body fat stores.

Thus, to some degree you could mimic the effects of fasting by strictly limiting carbohydrates.

Another line of thinking was that there can be a defect in how the body utilized carbs.

He also looked at the work of Dr. Alfred W. Pennington, who felt that the core issue was a defect in the ability of people who were obese to metabolize carbohydrates. Dr. Pennington was targeting reduction of carbohydrates and interpreting the resulting ketosis as evidence that removing the effect of the abnormal carbohydrate metabolism now freed the body to use fat as fuel. Ketosis as a hunger-suppressed state was not his goal, it was a sign that he was at his goal – sufficient reduction in the adverse effect of carbs. He was not concerned that protein intake would have any impact on ketosis.

J Clin Nutr. 1953 Jul-Aug;1(5):343-8.

Treatment of obesity with calorically unrestricted diets.

PENNINGTON AW.  PMID:13096572   LINK to full text. (takes a while to load)
I think most of what is discussed and speculated in this paper is not of current interest because the concepts are so dated and the discussion seems somewhat contradictory.  However, lots of times people find things that are useful in practice, even though they might not know how it works or their theories may be off the mark. Interestingly, Dr. Pennington emphasises that one of the important instructions for the diet is to eat sufficiently fatty meat. “The proper proportion is 3 parts of lean to one part of fat.”  If the meat is not fatty enough, then one is to buy extra fat (such as the fat from around the kidneys – apparently one could readily purchase that at the time) and cook it and have it with the meat. This work received attention because it was, at least in the short term, effective.
There were attempts to replicate this work by other researchers, including two in Europe, published in French and Swedish. There was also a report published in Canada.
“Experiences with the Pennington Diet in the Management of Obesity” by Wilfred Leith, published in The Canadian Medical Association Journal 1961 June 24; 84(25): 1411-1414.  LINK to full text.
They describe the Pennington diet as having the dual goals of (1) carbohydrates under 50 grams a day and (2) a strong focus on bulky foods. Having a lot of bulk in the meal was thought (and still is a topic) to be a major contributor to satiety. (I think this is actually a highly individual thing.)  However, I think this is their own spin on it, reflecting this team’s interest in bulk as a means to satiety. Dr. Pennington’s 1953 paper reveals no evidence of a focus on bulky foods (also his target was under 60 grams of carbs).

Why did they do the study? “The treatment of the obese patient has followed a stereotyped pattern for the past 20 years. Prescribing a simple low caloric diet and sympathetic handling of the patient, the usual method, had not been a rewarding form of clinical treatment. Usually, the patient was disturbed by a continual gnawing sense of hunger.”  Saying it like it is – not always a striking feature in medical writing today.

7 thoughts on “Ketosis in a Nutshell – Part 6, A Hungry Man

  1. Pingback: Nutritional Ketosis Overview | My Keto Haven

  2. Pingback: Ketosis in a Nutshell – Part 5, A Hunger Haven | it's the satiety

  3. Pingback: Ketosis in a Nutshell – Part 4, Happy Campers More | it's the satiety

  4. Pingback: Ketosis in a Nutshell – Part 3, Happy Campers Galore | it's the satiety

  5. Pingback: Ketosis in a Nutshell – Part 2, Crazy Little Things | it's the satiety

  6. Pingback: Ketosis series part 6 up, plus stories | My Keto Haven

  7. Pingback: Ketosis in a Nutshell – Part 1, What’s Up? | it's the satiety

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s