A Doctor with diabetes relates his health recovery with low carb nutrition.

In relation to the previous post regarding the video of Dr Tim Noakes, here is a short video of the Doctor mentioned by Dr. Noakes.

This video also communicates the points very well. Both videos were made by “karen skinny”, and I hope she keeps up the good work.

A comment I would make is that this does not at all have to be a high protein diet. In fact, some people do not get the full benefits of low carbohydrate nutrition if they embrace a high protein intake. A moderate protein consumption is usually best.

Also, note that he needed to pay close attention to his medications as he started the change in eating pattern. It would have been very dangerous if he had not reduced the diabetes medication and blood pressure medication as needed as his food intake changed.

Finally, I do not recommend the Dukan diet.

At 8:40 minutes, this video is also a good choice for helping you communicate with friends, family and your health care team about low carbohydrate nutrition.

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This video communicates well about metabolic syndrome and carbohydrates

Tim_Noakes_TEDxCapeTown_Ross_Hillier_lower_res

Tim_Noakes_TEDxCapeTown_Ross_Hillier_lower_res (Photo credit: TEDxCapeTown)

Professor Tim Noakes MD is very well known internationally as a runner and expert in sports medicine.  In this well done video, he describes how eating the recommended “prudent diet”, emphasising low fat and high grain intake, for 3 decades was accompanied by increasing weight and lack of sense of well-being, despite being an active athlete.

His health and sense of well-being have been turned around by adopting a low carbohydrate lifestyle. You can see in the video how happy he is with the results.

This is a good video to share with family, friends and your health care practitioners.

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Let’s just say it about hunger – 2

  • focus on hunger/satiety rather than some judgement about what should be the “normal” way to eat
  • the confusion of what is “usual” (a simple fact) with what is “normal” (a judgement)
  • carbohydrate load strain is simply about being metabolically non-alike
  • Metabolic diversity – laying claim to acknowledgement and respect

Continued from previous post …

Of course, I just had to post a comment to her, and her reply also deserves attention:

“Well, Dea, we could start by refusing to use the dominant discourse which insists we name the kind of eating (which I do) that provides satiety and eliminates hunger as “low carb” or “high fat”. Those are simply socially constructed categories that force people to think of eating for satiety as some WEIRD or anti-social or (OMG) UNHEALTHY way to eat. It’s “low” or “high” because the so-called authorities (corrupted by corporate influences, etc) SAY IT IS LOW OR HIGH. Crazy making, pure and simple. I’m done playing that stupid game of pretense–my lived experiences inform my choices now, not some “authorities” who don’t give an instant’s thought to my well being. They can’t. They can only spout whatever the “authorities” spout. There’s no relationship to whether it’s helpful for people or not. ARGH.”

This is exactly the kind of direction I’ve been trying to express in much of my writing on this blog, especially the recent 3 post series on Satiety Focused Weight Health. In fact, that is the reason for developing this blog in the first place. Hence the blog title “it’s the satiety” – that is, my view that a key missing ingredient to unlocking the weight control conundrum is to use a focus on satiety as both the essential process and a goal.

I have put my heart and soul into promoting a shift from focusing on “which diet” to focusing on the process of resolving struggles with hunger – which can only be done on an individual-by-individual basis using a trial and error approach to finding what they experience as worthwhile. The target – “weight heath with food peace”.  An individual “lived experience” exploration of hunger/satiety responses to carbohydrates in different amounts and forms is one of the key things to consider within that framework.

Still, we need some language to use when discussing this process of coming to understand one’s own responses to carbs. Whether you wind up eating “low” amounts of carbs or “high” amounts of carbs is not at all the point. The point is, are you having a carbohydrate load that is within your current ability to handle without strain or damage. Are you under carbohydrate load strain or not?

I also have to mention here that some people have clearly reported the “lived experience” that they can feel unwell when consuming carbs at (how shall we call it, we still need to use commonly understood terms to communicate) a “low” intake at various levels below about 100 grams per day.

If neither of these states apply to you, the amount of carbs you are having is just fine for you – and “high” or “low” become not judgement issues, but just matter in terms of practical issues, like finding recipes and exchanging practical ideas with each other.

There is a subtle difference between using “low” or “high” as relative terms that relate to some implied normal and using “low” or “high” as merely descriptive quantitative terms that relate to some factual usual.  “Usual” does not have to include any judgement value of desirable or “normal”. I am short, in that my height is factually below the usual height for women in my country. It is not customary in our society to regard “usual” height as implying a “normal” height, which would make me a deviant. Much confusion arises from mixing up what is “usual” with what is “normal”.

“Metabolic diversity” is the name of the game. I insist that my metabolic individuality be acknowledged and respected. I eat the amount of carbs that is “just right” for me. It is “low” compared to the usual intake. On the other hand, it is not “low” at all compared to any normal level, because there is no “normal carbohydrate intake” to be deviant from.

Related articles

Let’s just say it about hunger – 1

Dr Dea Roberts MD:

Re-blogged from Hopeful and Free. Saying it like it really is about her experiences with hunger. She has more to say on this topic in other posts and in the comments section. I’m an instant fan.

Of course, I just had to post a comment to her, and her reply also deserves attention:

Note: the rest of this post is just not appearing in proper formatted form. I have tried repeatedly to fix this and no go. Unfortunately, I have to break up this post.  Please see the next post for the continuation of this topic. Thanks for your patience.

Originally posted on hopefulandfree:

I used to believe that most of my hunger was not REAL hunger. I thought my hunger was (based on my necessary-for-a-time yet distorted way of thinking) a product of my imagination. That false belief about reality—about my REAL hunger—was based on *social truths* that I had heard so many times…well, hell, they just HAD TO BE true.

Because, otherwise, it meant I was living in a sick cruel world whose constant and most authoritative discourses (medical, academic, psychological, journalistic, etc) TOLD ME falsehoods and distortions about my life and my shared existence with all other humans.

That, that terrifying possibility just described, was more painful to consider and believe than my belief (and my eventual *trust*) in my own apparent *pathology*—my own so-called sickness, my so-called weakness, my self harming ways, my lack of knowledge, my…my own BADNESS.

Yes. Far less painful for me to accept my own personal…

View original 1,833 more words

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.

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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.

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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.

A pediatrician loves the LCHF outcomes

Eating Avocado

Eating Avocado (Photo credit: chimothy27)

There is an inspiring new post on the blog Low Carb Pediatrician.

The post is titled “A Picture is Worth a Thousand Words (Part 2)”, and is it ever.

Dr. Brad Hoopingarner MD, FAAP, also known as Dr. Hoop, who writes the Low Carb Pediatrician blog, started advising his patients about low carb, high fat living 3 years ago and hasn’t looked back.

In this post, he shares pictures of the BMI charts of several of his patients who have had happy experiences with living LCHF (low carb high fat). Of course, the children’s privacy is protected and no identifying information is given. Congratulations to the kids on their accomplishments and thanks to them for permitting their data to be shared.

Access Dr. Bernstein – diabetes control with low carb

Aside

Diabetes Solution

Diabetes Solution (Photo credit: Earthworm)

Every month the highly-respected Dr. Richard K Bernstein has a teleconference.

From the email I received:

“Ask Dr. Bernstein Webcast and Teleconference !!! – TONIGHT!  Wednesday, Oct 31, 2012 Special Topic Diabetes/cancer and CVID

Please Ask Dr. Bernstein Your Questions NOW! By emailing us at publisher@diabetesincontrol.com or by going to www.askdrbernstein.net
Join the Ask Dr. Bernstein Webcast and conference call on Monday Oct 31,2012 7PM CST, 8PM EST and 5PM West Coast Time. Dr. Bernstein will answer your questions

To attend, visit: http://cdset.c.topica.com/maapWXOacaxnobtVXqrbaeQyvr/
Or Primary dial in number: Phone number: (206) 402-0100 PIN Code: 900326#  “

(Note: for Canadian readers, this is definitely not the Dr. Bernstein of the diet clinic chain.)

Dr. Bernstein has endeavored over many decades to get out his message of blood glucose control to normal levels, and the essential role of low cab intake in that process.

The medical literature starts to shift

Eggs

Eggs (Photo credit: pietroizzo)

That creaking sound you hear is the slow reluctant shifting of the medical literature.

We are starting to see more medical papers and research that reflect the concepts of addressing carb intolerance by reducing carb intake – and thus increasing fat intake.

(1) It is not surprising that this is a well done study – note Jeff Volek as one of the authors:

Whole egg consumption improves lipoprotein profiles and insulin sensitivity to a greater extent than yolk-free egg substitute in individuals with metabolic syndrome.

Blesso CN, Andersen CJ, Barona J, Volek JS, Fernandez ML.

Metabolism. 2012 Sep 26. pii: S0026-0495(12)00318-6. doi: 10.1016/j.metabol.2012.08.014.  PMID: 23021013  LINK to abstract

Note that the study participants were not eating low carb – they were having 25-35% of their diet as carbohydrates – which is still a lot less than the carb intake in the “usual” diet.

The study results carry an extra meaning in that this supports the concept that there are many differences in metabolism between people who are eating a carb load that is under or over their personal tolerance limit. Thus, given that carb intolerance is so wide-spread in the general population, any research done on people eating “usual” amounts of carbs cannot be assumed to apply to people eating carb amounts that are within their carb load tolerance. This applies even more so for those eating very low carb or who are adapted to a state of nutritional ketosis.

Thanks for heads-up on this study to a tweet from @CavemanDoctor.

(2) Thankfully, full text is on-line for this extensive review article:

Sugar restriction: the evidence for a drug-free intervention to reduce cardiovascular disease risk.

Thornley S, Tayler R, Sikaris K.

Intern Med J. 2012 Oct;42 Suppl 5:46-58.  PMID: 23035683   LINK to full text

You can click for the PDF version, which is easier to read.

Another Low Carb and Happy Story

Bicycle Lane

Bicycle Lane (Photo credit: snofla)

I am enjoying Meghann Douglas’s blog Meghann’s Meltdown. It took me a while to get it about the title – she has lost over 100 pounds.

She incorporates a lot of activity, such as swimming and biking, into her day.

From one of her recent posts:

http://www.meghannsmeltdown.com/blog/2012/9/19/data-the-key-to-taking-control.html

“I resisted keeping data logs for a long time.  ……  As the importance of the carbohydrate/insulin imbalances became clearer to me, the more important it became to accurately measure and track those carbohydrates.  “Close enough” is not enough.  It’s work to monitor closely enough to stay under 50 grams of carbohydrates per day.  The difference in how I feel makes it worth the while.  The reduction in pain is worth it.  Thank goodness for online programmes and their phenomenal databases.  Calculating & balancing my own ration is vastly improved from all those livestock rations I used to balance!!!!

There’s another important side of this.  You need to keep that food log in order to be sure you’re actually eating ENOUGH.  This is a totally oddball concept to work your head around.  I have literally spent my life counting calories and fighting my own hunger (real or imagined) and the cravings.  Your biggest nemesis is that magic number you’ve chosen to never exceed.

Balancing our own low-carb food plan has almost completely eliminated ALL cravings.  Even further than this, you can forget to eat because you just don’t feel hungry.  You can look at things you couldn’t walk past before and honestly not even want them.”

Ketosis in a Nutshell – Part 4, Happy Campers More

shrimp (boiled), lemon juice, fresh cream, may...

shrimp (boiled), lemon juice, fresh cream, mayonnaise, salt, chervil (Photo credit: Wikipedia)

Nutritional Ketosis and Weight Loss

The other significant intentional use of nutritional ketosis has been for weight loss and weight control.

To be clear, nutritional ketosis is just one tool that can be used to assist with weight control. It is not suitable for everyone. Even for the people who do find it useful, the benefits will not be limitless. Many factors are involved in weight control, such as sleep and stress - it does not all come down to diet.

OK, Now for the Stories of Happy Campers -

Uhm, wait….

Yes, I do have some stories for you – two in particular make for very interesting reading. The most fascinating is the personal story of Dr. Atkins himself.  I will get into these stories, but first it is important to discuss some areas of confusion.

It is not such a simple matter to find stories for the topic of weight loss as it was for the previous topic of epilepsy control. Why? In the situation of ketogenic diets for epilepsy control, nutritional ketosis has been the agreed-upon target from the beginning (although this is changing with some of the less strict dietary regimes of the past decade).  The people were following strict diets that would clearly induce ketosis and these were consistently maintained over time (in those who had success with their seizures). They were all under the guidance of professional expert teams and meaningful research data was collected and published. When considering nutritional ketosis in the context of weight loss, the situation is much less clear.

Isn’t following a low carb diet about the same as being in ketosis?

Don’t we know all about this from the wide use of low carb diets over the past decades?

When people follow a very low carbohydrate eating plan, such as what is commonly thought of as “the Atkins Diet”, most of them will be in nutritional ketosis. (I put “the Atkins Diet” in parentheses as often people are following some concept of their own of what the Atkins Diet is, rather than truly following Dr. Atkins’ actual recommendations.) Some people will not be in ketosis – for various reasons their metabolisms are resistant to going into ketosis and/or they may be consuming an amount of protein that is too much for them.  Some people may be testing to monitor over time whether they are in ketosis or not.  Some are not.  As people start to eat more carbohydrates or more protein, individual people will move out of being in ketosis at different amounts of carbohydrate or protein intake.

Therefore, everyone who is in dietary ketosis is eating a low carbohydrate diet (unless they are taking a ketone-producing medical product or eating high amounts of medium chain triglycerides). However, not everyone eating a very low carbohydrate diet is in dietary ketosis.  It is now very clear that you can be carefully following a very low carbohydrate diet – for example, staying below 20 grams of carbohydrates a day – and yet not be in nutritional ketosis to any meaningful degree.

Unfortunately, the two things seem to have gotten somewhat mixed up together in many people’s minds.  I think somehow being in ketosis – turning the urine test strip purple – has come to be commonly viewed as just the far end of the low carb spectrum. In reality, being in ketosis is a metabolic state of its own with effects and implications that go beyond just leveling out the blood sugar levels, or lessening swings in insulin or other benefits of lessening the strain on the body from carb intake above an individual’s tolerance level..

What’s the big deal? Why does this matter?

  • being keto-adapted can help weight loss and weight control
  • the changes that happen with ketosis, if not understood, can interfere with weight control by causing confusion and discouragement

How can being keto-adapted help with weight control beyond a low carb lifestyle?

(1) Being in sustained ketosis provides some degree of lessening of appetite (more below).  This knowledge has faded from awareness or not been appreciated for the invaluable tool that it is.

(2) Some people might have a benefit to their brain function that results from their keto-adaptation. (See previous post in this series.) We don’t know enough about this yet, but many people report improvements in mental energy, focus and mood – these effects could be expected to improve a person’s ability to control their weight.  Scientifically, these effects are quite plausible and I hope the current interest in research on ketosis and brain function will expand quickly.  This is just speculation, but it is even plausible that being in ketosis may favour improved function of the appetite/satiety control centres of the brain if these centres might be (hypothetically) metabolically compromised in their function??  This topic is particularly interesting in view of the current concept of “Type 3 diabetes” (see the second post in this series).

(3) There may be other aspects of being keto-adapted that might be helpful in weight control – for example, some people feel that their muscles function better when in ketosis and then find it easier to be active. Some athletes are now using keto-adaptation as a high performance strategy. See HERE and HERE and HERE.

How can ketosis cause confusion during weight loss?

If you are transitioning into ketosis and you are not well informed about what that means or how that can be expected to affect your body and your energy metabolism, you could be very confused or even distressed by changes you experience.  Without proper information, you might not even know you are going into ketosis.  You might not even understand that the way you are eating has made ketosis a possibility.

The same is true in reverse if you are in ketosis (intentionally, knowingly or not) and you unknowingly move into a slight degree of ketosis (where you are not really running substantially on ketones) or fully out of ketosis.

(1) rapid weight changes not related to changes in fat stores

When transitioning into ketosis, there is a rapid drop in body stores of glycogen, which causes a rapid drop in body weight from the weight of the glycogen and the water that had been associated with the glycogen. There is also a increase in sodium excretion, with some drop in body water from that, as well.  None of this weight is actually loss of body fat stores.  This can lead to false expectations of continued rapid weight loss.

Over time, the body adapts to the state of ketosis and there is some re-balancing in the body.  In terms of any regain of that body water, I don’t think there is much definitive to say at this point and it is bound to be highly variable between individuals.  However, to the extent that there were a slow regain of some of that water over the first 2-3 months, this would show up on the scales and falsely appear to be lack of progress in reduction of body fat.  The more dramatic the initial drop in body weight as water, the more chance that some return of that body water could, soon thereafter, give an impression of lack of progress in fat loss.

It can be very easy to move out of the ketotic state. One substantial serving of carbs can mean that the next day your body weight shoots up just as rapidly as it initially fell.  Only a very little bit of this would be actually fat – almost all of it would be water and glycogen.  This causes people great unhappiness and confusion and can precipitate a dark mood that then brings even further “off-plan” eating.

(2) changes in energy and sense of well-being

When you are transitioning into nutritional ketosis, you can feel quite “low” and tired for a few days or even a week or two as your body adapts to the new fuel mix.  Some people even call this “the Atkins flu”.  It will pass and there are ways to lessen these effects (such as increasing sodium intake – see Resources below).  The real problem comes if this is happening to you and you don’t understand why.  Once the transition period is well underway, people often feel better than they have in some time.  Imagine how confusing it is if these changes come and go unpredictably and with the real cause unknown and thus uncontrollable.  If the person moves out of ketosis for a few days, they may suddenly feel a real change in their sense of well-being.  If they then shift back into ketosis, it will take some days or a week or two again for them to get back to a keto-adapted state.

Without knowing the real cause for there mysterious changes in how they feel, they may incorrectly blame the problem on something else and start making other changes in their diet or lifestyle or health practices that can then lead to other confusions.  None of this bodes well for finding their best personal happy healthy stable eating pattern

(3) changes in appetite and cravings for starches and sweets

  • loss of the appetite-suppressing effect of being in ketosis
  • suddenly the brain is not getting the ketones it is adapted to, so it quickly starts using much more glucose than the liver has been used to supplying, potentially drawing down the blood sugar level.  When the brain gets hungry, it sends out signals to supply it with its emergency fuel – glucose.
  • when coming out of ketosis, for a few days the body is not fully adapted to glucose intake again and the blood sugar will go higher than it normally would, risking an exaggerated eventual insulin response which would compound the problem by causing an unusually sharp drop in blood sugar.  Remember that starch is pure glucose, so it isn’t just sugar that causes a flood of glucose into the body. The rapid drop in blood sugar would bring more hunger and a craving for carbs to bring the blood sugar back up. Repeat. Repeat again. By the time this roller-coaster settles down, several days have passed and the person has regained glycogen (and therefore a number of pounds) and can be very discouraged and also not understand what just happened to them.

Imagine a person who had become adapted to being in a sustained state of ketosis who then shifted their diet so slightly that they did not notice or did not think it was a significant.change. Imagine that person thinking that they were still following the diet, but they were no longer in ketosis.  They would not understand why suddenly they were both more hungry and having craving for carbohydrate foods.  They would just feel that “the diet stopped working” or “I don’t have the will power to stick to the diet”. A bit of extra hunger or craving, if due to being close to moving out of ketosis, can bring “a little nibble”, which would then be sure to bring a bit more hunger or craving.  As the ketone level then fell further, a few “nibbles” more would again cause more hunger, not relief of hunger. This hunger leading to more hunger is often the path that leads a person fully out of ketosis – and into a sharp spike and drop in blood sugar, as well, depending on the foods and amounts chosen.

There are many happy stories of sustained weight loss while eating low carb.

But very few that include (adequate) details about the topic of ketosis – although this can be expected to change dramatically over the next months.

Over the decades and until very recently, relatively few of the people who have reported their experience with low carbohydrate diets have included in those reports enough (or any) detail on their experiences with ketosis itself in order to be able to understand the impacts of nutritional ketosis on their experiences – both good and bad.

Thus, the stories of those people who actually experienced a sustained period of nutritional ketosis are, for the most part, not clearly separable from the stories of people who undertook low or very low carbohydrate diets without a period of being adapted to nutritional ketosis.  Generally, the stories of people who had problems with weight loss on low carb diets – or who found staying on the diet too difficult – do not contain information on whether they had attained keto-adaptation and what was going on with their ketosis situation during the time when they were having difficulties.

Stories of experiences with nutritional ketosis can be suspected within stories of people who have followed low carbohydrate eating plans.

When you hear or read stories of people’s experiences – good or bad – with following a low carbohydrate eating plan, keep in mind how their encounters with ketosis may have been a factor in their experiences with low carb.

Stories That are Clearly About Nutritional Ketosis for Weight Loss

(1) Patient Number 1 – The original Happy Camper using nutritional ketosis as an aid in his own weight loss – Dr. Robert C. Atkins.  Unfortunately, this post is getting too long already, so I will have to leave as this teaser – from how I read it, Dr. Atkins’ original focus was just as strongly on the vital role of nutritional ketosis as it was on the problems of carbohydrate intolerance.

(2) The story that is creating Major Buzz is Jimmy Moore’s recent experience, which he has been documenting in detail since the spring.  It should be pointed out that each person’s needs and medical situation is different, so his story is not intended to imply that his approach is for everyone or is the most healthful way for you to proceed.

I include it here because it highlights the difference between a very low carb diet and a targeted ketogenic diet.

I expect that few people would have an outcome as dramatic as Jimmy’s.  He obviously is able to go into a strong level of ketosis and feel very well while doing so.  People are very different in how readily they go into ketosis and how they respond to it. As I’ve said before, ketosis is not right for everyone. Jimmy’s response is in keeping with his earlier experiences of dramatic weight loss when he first went on a very low carb eating plan in 2004.  His results then were similarly “not typical mileage” – with a much more dramatic weight loss than many people achieve with the same diet changes.

(3) Jenny Ruhl’s recent experience - You have to scroll down to the comments section below her post to see where she reports that she did test positive for urine ketones throughout the trial 2 weeks, after the first couple of days. I include it here for some balance.  Also, it reflects some other people’s experiences that I have read about in the past months where the person has done blood testing for ketones and not had substantial weight loss when eating to satiety.  Note – in Jenny’s trial she did lose weight, but she remained hungry as she kept to a calorie cap.

What you eat is only part of the whole picture when it comes to what is determining your body weight (unless being in semi-starvation or putting up with chronic hunger, neither of which are tenable long-term).

Jenny is an extremely happy camper when it comes to a “to the meter” individually targeted lowering of carbohydrate intake as an essential aspect of controlling diabetes and glucose intolerance (see her other web site, facebook and books).

(4) Tommy Runesson in Sweden - very impressive weight loss, now stable at healthy weight.  Recently doing blood ketone testing and reporting this in detail on his blog.  Great blog for seeing the very tastey-looking food he photographs daily.

(5) More stories with testing of blood ketone levels are bound to be appearing in increasing numbers over the next months.  We really know only tidbits of info so far about this whole topic.

Places I would suggest to keep an eye out for more stories over the next months:

To be continued … this post has gotten too long.

Next: more on the topic of appetite reduction in nutritional ketosis and a look back almost 5 decades ago to the insights that started it all for Dr. Atkins.

Resources – Link to my page Resources – Low Carb and Ketosis

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