Ketosis in a Nutshell – Part 5, A Hunger Haven

Posted on October 17, 2012 by Dr Dea Roberts MD

Being in nutritional ketosis reduces hunger.

Just that.

It is worth taking a full pause and letting that sink in if you are not already well familiar with this.

You don’t have to be overweight for nutritional ketosis to have this effect:

- you don’t have to be trying or wanting to lose weight

- you don’t have to have metabolic syndrome

- you don’t have to have blood sugar problems

- you don’t have to have insulin problems

- you don’t have to have any problems with carbohydrates.

You don’t have to be a person who would otherwise be interested in a low carbohydrate diet in order to have this response to being in nutritional ketosis.

As mentioned in Part 2, this is simply a normal usual aspect of how your body functions when adapted to being in a sustained state of nutritional ketosis – that is, when “keto-adapted”. (list of terminology is at the bottom of Part 1 of this series)

In any situation where persistent hunger is interfering with achieving health goals, consideration can be given to a careful trial of nutritional ketosis. This would also likely be true in many or most situations where the urge to eat was felt or interpreted as “cravings” rather than as “hunger”.

It won’t be appropriate in all situations and it will not suit all people.

“Reduces” hunger – not “eliminates” hunger

nutritional ketosis is part of our normal physiology, so we can adapt to different food availability situations. It would not be very pro-survival if it made people totally disinterested in finding or eating food. Your body doesn’t want you to be so disinterested in food that you become malnourished, start to waist away or starve.
in nutritional ketosis, if you ignore or over-ride your body’s signals to eat or to consume fluid you can go into an unhealthy state of higher ketones and dehydration that can be associated with loss of appetite (and vomiting, nausea and sleepiness) – but this does not happen under normal circumstances where a person is not fasting or skipping meals. It has been noted to happen sometimes during the initial transition to ketosis in the treatment of epilepsy – but this transition has traditionally been done with an initial period of fasting. Under “normal circumstances” you are responding to your body’s signals for food and water – not refusing available food when you are hungry (no surprise if this turns out to be not a good idea).

We don’t know a lot about this so far:

people vary in how easily they go into ketosis (how much they need to restrict carbs and whether they need to consciously restrict protein)
people vary in the level of blood ketones they have on similar food intake
people vary in how they feel at different levels of blood ketones, even when there has been a period of adaptation
people vary in how much they have a lessening of hunger when keto-adapted, although there tends to be more appetite suppression at higher ketone levels
people vary in how much their bodies use their own body stores of fat for fuel

As we understand it for now, the lessening of hunger and the use of body fat stores go hand in hand. If body fat stores are being mobilised from the fat deposits, and being burned for energy, there will be less hunger signals saying “eat more”. If, for some reasons (or many reasons) the fat stores are not being mobilised, the body will signal for more food intake.

Contrary to rumour, there is nothing about being in ketosis that guarantees weight loss. You can be well-established in a state of keto-adaptation and not lose weight while eating to satiety. You are still in a state of burning primarily fat for fuel, but it is fat from the food you eat, rather than from your body. Having ketones in your blood or urine does not indicate where the fats are coming from that you are burning.

I don’t think there has been any research on this, but it seems pretty clear from people’s experiences that you can be in at least a mild state of ketosis and gain body fat stores. I really don’t see a reason why not.

Using Nutritional Ketosis as a Tool in Weight Control

Context is everything – best health requires an individualized holistic approach.
What does it look like when this is going well?
What is going on when things are not going well?
Concerns? – There are always concerns.

(1) Using Nutritional Ketosis within a Satiety-Oriented Approach to Weight Health

(I digress – I can’t brush this close to my bug-bear topic without touching it – if this is not of interest to you, please skip ahead ’till you see #### .)

There are two types of harm associated with high amounts of body fat stores:

what we usually think of – the harms from high body fat itself, from visceral fat, from associated conditions both as causes and consequences of obesity/visceral fat, from emotional impacts, from prejudice and discrimination, and so on.
the harms caused by what people do in their efforts to avoid weight gain and reduce body fat stores

I think this second type of harm has been underestimated as a major driver of the current obesity epidemic – and I mean this separately from the topic of diet composition in terms of carbs, fat, etc. I am particularly concerned about the potential for harm when the public has the impression that the medical community and policy bodies view putting up with sustained hunger as benign, as effective and as an advisable strategy for weight control.

I consider that calorie-restricted dieting, which intrinsically includes the instruction to not eat when hungry if the calorie limit has been reached, should generally be reserved for situations where a satiety-focused approach is, for some reason, inappropriate or not effective or not effective enough.

What does a ”Satiety-Focused Approach” mean? (see also Overview)

General health, individual circumstance, over-all quality of life and individual goals take precedence over total body fat when considering body composition targets, as is true in all situations where there is consideration of body fat stores.
If reduction or stabilization of body fat stores is desirable and this is not occurring, interventions are chosen that don’t require restriction of food intake in the face of sustained hunger (no imposition of a calorie cap).
The interventions are designed to facilitate achieving satisfactory satiety with no excess hunger (i.e. hunger other than in the pre-meal period) while undergoing weight loss.
Failure to meet the chosen goal (whether weight stabilization, reduction of body fat stores, more food “peace”, etc.) over time is a valuable feedback from the body that more needs to be done to reduce appetite drive and facilitate satiety.
Any attempt to impose a calorie cap will ruin this essential feedback and risks sabotaging progress towards a successful long-term strategy (which will actually be composed of a combination of strategies).

The most ideal outcome is to have the appetite/satiety control system performing its proper function of maintaining a healthy body weight and, if the body weight is too low or too high, nudging the body towards reaching that person’s best body weight.

Things that favour improved functioning of the appetite/satiety control system are intrinsically things that favour health in general and the over-all best functioning of the body. There are countless things that can disrupt appetite/satiety control.

Just to give a few examples, for some people, simply resolving one of the disrupters below might be enough allow recovery of appetite/satiety balance:

getting enough sleep
dealing with stress
re-establishing regular eating patterns, including breakfast (avoiding restrict/rebound patterns)
becoming able to safely reduce, change or stop certain medications that may be interfering
avoiding high-sugar liquids.

One of the most important and effective things that can be done to favour proper functioning of the appetite/satiety control system is to consider whether the person is under any form of harm or strain from the amount and/or type of carbohydrates in their diet. At the present time, in Canada and in all the “developed” nations of the world, the biggest cause of ill-health in the area of nutrition or metabolism is carbohydrate intake in amount/type that is beyond the individual’s current ability to handle without adverse impact (what I think of as “glucose load strain“) – causing metabolic ill-health and its consequences. I think this is having more ill-health impact than obesity itself.

An individually tailored change in type of carbohydrate, with or without a reduction in total amount of carbohydrate, will help many (not all) people who struggle with their weight or who are normal weight but have excess visceral fat. This strategy can help the appetite/satiety function by:

lessening swings in insulin and demand for insulin, thus lessening exposure to high blood levels of insulin
lessening swings in blood glucose
making control of blood glucose much easier in diabetes or pre-diabetes
thus helping to preserve health (which helps preserve future ability to control weight) and reducing requirements for medications – with their potential for side effects
avoidance of trigger foods in those with sugar craving/addiction or food craving/addiction that involve sweet taste, starchy foods and/or foods that mix sweetness, sugars or starches with fats.

It’s not all about the carbs. However, your carb intake is something that you have control over, whereas you might not be able to do as much as you would like about your sleep, your stress, the medications you require, your level of chronic pain, and so on. Still, long term results are best served by the broadest possible effort to maintain your health. (Remembering that carbs are not just about weight and, in fact, the impact of carbs on metabolism is much more important.)

With a satiety-focused approach, improving weight control rests on improving general health, including burdens on body function and regulation. Doing the most possible to promote appetite/satiety function equals doing the most possible to promote health and un-burden the person and the body.

This will not always be enough. There may be disruptors that, at the present time at least, cannot be resolved. There may be essential medications that can’t be safely stopped, there may be unresolvable sleep problems, there may be long-term consequences on body regulation that have been brought about by high body weight or by losing substantial amounts of weight, and so on.

If it can’t be “fixed”, find a “patch” or “work-around”. ####

When a person’s appetite/satiety control system needs a little extra help, from my point of view the first choice “work-around” to give consideration to is taking advantage of the appetite-suppressing effects of nutritional ketosis. (Recognizing that there are other weight control or “obesity management” interventions that derive all or a major part of their effectiveness through their impact on appetite/satiety balance including obesity management medications and surgeries.)

A very high exercise level could be considered to function as a “work-around” in those individuals for whom it results in reaching a balance point of calorie expenditure versus appetite.

Calorie restriction remains an option in considered situations and for some people this can be very useful and become their favoured, successful and long-term intervention. It should certainly be tried before obesity management surgery and should be at least considered and offered before obesity management medications.

(2) What Does it Look Like When Things are Going Well?

I refer you back to two of the stories I link to on the previous Part 4, near the bottom of the page.

Jimmy Moore’s story is the best that I have seen in terms of demonstrating the difference between his experiences with a very low carb eating pattern and his experiences with nutritional ketosis. Not everyone will feel the difference between the two as profoundly as he has and certainly most people will not have such a dramatic weight loss. (links below)
Tommy mentions in one of his blog posts that he was starting to have a little weight regain after holding stable for years. He took advantage of blood ketone testing. He tightened his diet, succeeded in increasing his blood ketone levels and this helped with his weight.

(3) What is Going on When Someone Who has Plenty of Fat Stores is Keto-adapted and Not Losing Weight?

We don’t know. The short answer is that they are not having enough suppression of appetite to allow their food intake to drop down enough to allow weight loss.

I know that’s not much of an answer, but it is the state of the art at the moment.

As I see it, there would be at least these four things to consider:

(1) The body may be defending the fat stores that are present because of some signalling that is giving the message that the body fat stores are getting low or for some other reason need to be defended:

this might be considered “appropriate” – for example, a woman of 5′ 2″ who is finding that her weight loss is stalled at 120 lb. when she wants to get to 115 lb. I sympathise, but her body “has a mind of its own”
or “inappropriate” – for example, someone who’s weight loss stalls when they are still 50 pounds above the “normal” weight category – perhaps the body is getting erroneous signals that fat stores are low or for some other reason need to be defended

(2) There may be something (or many things) interfering with mobilising fat from the fat stores. In this situation, the person can still be in ketosis as long as they satisfy their hunger by mostly eating fats, and keep their carb and protein intake low enough. This can still be very valuable in helping prevent weight regain, helping prevent cravings and “unintended” eating, and other potential benefits.

(3) The level of ketosis may not be enough for that person to have enough appetite suppressing effect in order to allow food intake to fall enough to achieve weight loss.

there may be something interfering with the ability to burn enough fats (whatever the source of the fat) to meet the majority of body energy needs – whether due to a disease, toxic influence, medication or a rare genetic metabolic problem.
the intake of carbohydrates and/or protein may be too high to allow ketosis for that person at that time.
the internal supply of carbs may be too much – continued next paragraph.
if the internal supply of carbs can be too much, I wonder if the internal supply of protein can occasionally briefly be too much – such as when tissue is being broken down after an injury or after very intensive exercise or when there is bed rest, particularly in someone who has developed and maintained large muscle mass through regular exercise. I haven’t heard anyone comment on this and this is just speculation on my part.
if the person is not very active and has a relatively slow metabolism (generally people’s metabolism slow a bit with the passing decades and people who have lost weight can have a slowed metabolic rate long term) they really may not need to eat very much. They still need their protein for their body lean mass. Once they have that protein and a bit of carbs in their veges and possibly a few nuts or cream or cheese, they may not actually be burning a very high amount of fat to counter-balance that.

The internal supply of carbs being too high is what is happening in the first couple of days when transitioning into ketosis, as the liver’s supply of glycogen is depleted. The liver produces glucose from glycogen, certain of the amino acids (components of protein), as well as a bit from fat molecules. The glucose is sent into the blood stream to prevent the blood glucose level from falling below normal range. The liver does this mostly under the direction of glucagon and the stress hormones — that is really a rough account, I can’t say I’m really up on the details.

If the blood glucose level is falling and the liver is not keeping up with need, a sudden surge in hormones can bring a surge in glucose output. This most often happens with exercise and during the night, especially in the early morning and pre-dawn hours. When a sudden surge in hormones is triggered, this is not a finely calibrated response. The resulting glucose output is generally more than what is needed. In someone with diabetes or glucose intolerance, this may show as a rise in blood glucose above normal, and insulin secretion will go up if their body has the ability to do so. In someone with normal insulin function, the rise in glucose will not be above the normal range, because insulin will go up to handle the glucose. Any rise in insulin inhibits ketone production.

Besides sudden surges of stress hormones, many people have raised stress hormone levels at various times of the day and night. Many people have chronic elevations of stress hormones, particularly as they get older, and particularly at night.

I wonder if this has a bit of a role to play in why it is so famously difficult for post-menopausal women to lose weight. This is a very large topic and this suggestion is not meant to over-simplify the picture, but, as a general group, post-menopausal women are famous for having poor quality sleep – and even more so if they have hot flashes or night sweats. Some women in this situation may be producing enough glucose at night to trigger enough insulin to suppress ketone production. This would not be detected by blood glucose testing if insulin function was normal.

Also, insulin resistance of the liver is common. In this situation, the liver may produce substantially more glucose than is needed to maintain the needed blood glucose level.

(4) due to insulin resistance, when starting the diet insulin levels may be quite high and may take a while to come down to lower levels. Besides this, if the person has been habitually having a large amount of quickly-absorbed carbs at their meals, there body is adapted to this pattern. When they first adopt a low carbohydrate eating plan, this may take a few days to settle down, and in that time the person will be hungrier and hungrier more often.

And … there is always the unexpected unknown. As mentioned in Part 4, Jenny Ruhl has had some difficulties with very low carb diets, despite being unusually well informed and experienced. We do know that Jenny has an unusual metabolism in that (1) she has an uncommon form of diabetes and (2) she had a very unusual (though very pleasing) profound response to Co-enzyme Q10). The thing is, unusual metabolisms happen, and you might not know about it until later life.

Addendum Oct 18/12 – I knew I was forgetting some things in this list:

nutritional ketosis is just one influence on your appetite/satiety system. If you have enough pro-appetite forces in your life, the effect of these may be stronger than the appetite-lessening effect of the keto-adaptation. The Rest of Reality always applies.
when you start into nutritional ketosis, you may be still in a restrict/rebound cycle. The restrict/rebound cycle can take place within a day (low food first part of day, over-eating in later day), within a week (skimping food in week and rebound on weekend) or over months (“dieting”, then rebound after the diet) or over any other time period. If you have just spent time deliberately eating less than your body is telling you to, even though you might then switch to a healthier approach that would be successful long-term, you still might have to go through the rebound phase set in motion by your previous restriction. This doesn’t mean you have to re-gain the weight, but you might re-gain some (e.g. rebuild muscle) or stall for a while until your body figures it has repaired and recovered from the forced weight loss. To help this process, be kind to yourself in other ways, to promote recovery from the previous dieting stress – especially, don’t heap on more stress.
if you have lost weight recently, you may be in a ‘stall” or “plateau” that you just have to wait out. Stalls happen to every-one.
sights, smells, thoughts - your appetite/satiety system is integrated with your entire functioning. Seeing and smelling food already sets the digestive system in motion. You may need to be careful how much you are exposed to foods that are of a type you are not intending to eat. Thoughts matter – find other things to enjoy and be cautious about negative self-talk. If you are exposed to food that is in keeping with your intended eating plans and you feel hunger – eat it (or, if that’s illegal, find food you own and eat that).

(4) Concerns About Nutritional Ketosis for Weight Control?

There are always concerns …..I have mentioned some of these near the bottom of Part 1 and in Part 2 and I’ll get back to this topic in a later post. (likely 3 more in this series)

……………………………………………………..

The field is starting to move quickly. As I have been preparing this, an important post has appeared on Dr. Richard D. Feinman’s blog (the biochemist, listed in my blogroll). The post is by Dr. Eugene Fine and he explains a research paper just published. The purpose of the research was to examine insulin lowering as a strategy in cancer treatment. I expect research interest in this topic to expand rapidly. Now it is in its very earliest stage and there are only baby steps towards a good working knowledge.

The point of interest in Dr. Fine’s post that relates to the topic of this post is the graph of insulin levels versus blood beta-hydroxybutyrate levels (the type of ketone measured when using blood ketone testing – also noted as beta-OHbutyrate) and how variable the ketone (beta-hydroxybutyrate) levels were between the participants when on a ketogenic diet even when strict care was taken to use diet compositions as identical as possible. Also, they clearly noted appetite suppression.

“(We tried to over-feed the patients in order to maintain weight and calorie intake, but it didn’t work: very low CHO diets do indeed cause spontaneous calorie restriction and weight loss, even when you try to prevent that.)”

To hear more about Dr. Eugene Fine’s work, look for Jimmy Moore’s upcoming podcast with him on Monday, October 22, 2012

To hear more about ketogenic diets and cancer, look for Jimmy Moore’s Ask the Low Carb Experts podcast tomorrow, Oct 18/12 with Dr. Colin Champ.

Ketosis in a Nutshell – Part 1, What’s Up? (itsthesatiety.com)
Ketosis in a Nutshell – Part 2, Crazy Little Things (itsthesatiety.com)
Ketosis in a Nutshell – Part 3, Happy Campers Galore (itsthesatiety.com)
Ketosis in a Nutshell – Part 4, Happy Campers More (itsthesatiety.com)
Ketosis in a Nutshell – Part 6, A Hungry Man (itsthesatiety.com)

Jimmy Moore’s n=1 Experiments: Nutritional Ketosis Day 121-150 (livinlavidalowcarb.com)
Before And After Pictures Of My 50-Pound Weight Loss On Nutritional Ketosis (livinlavidalowcarb.com)

…………………………………………………………………………………………………

Some Research:

Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum.

Johnstone AM, Horgan GW, Murison SD, Bremner DM, Lobley GE.

Am J Clin Nutr. 2008 Jan;87(1):44-55. PMID: 18175736 FULL TEXT

“In conclusion, the low-carbohydrate component of the high-protein regimen affects subjective motivation to eat, and volunteers feel less hungry and consume less energy, at least in the short term. Whether LC (ketogenic) diets are a suitable tool for weight loss will remain an important issue for some time, as more complex interactions between phenotype and diet composition are identified (23). This regimen appears to reduce calorie intake without increased hunger, and, therefore, it promotes compliance.”

………………………………………………..

The effects of a low-carbohydrate ketogenic diet and a low-fat diet on mood, hunger, and other self-reported symptoms.

McClernon FJ, Yancy WS Jr, Eberstein JA, Atkins RC, Westman EC.

Obesity (Silver Spring). 2007 Jan;15(1):182-7. PMID: 17228046 FULL TEXT

“Hunger was significantly lessened in the LCKD group for as long as 3 months.”

“Furthermore, the present findings represent a replication and extension of previous studies demonstrating significant appetite suppression during an LCKD.”

Ketosis in a Nutshell – Part 6, A Hungry Man (itsthesatiety.com)

Ketosis in a Nutshell – Part 4, Happy Campers More

Posted on October 14, 2012 by Dr Dea Roberts MD

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.

Jimmy Moore’s n=1 Experiments: Nutritional Ketosis Day 121-150 (livinlavidalowcarb.com)
Before And After Pictures Of My 50-Pound Weight Loss On Nutritional Ketosis (livinlavidalowcarb.com)

(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).

Final Update: My Experimental Diet (diabetesupdate.blogspot.com)
interview and call-in podcast with Jimmy Moore Sep 22/12 for more background on the problems she encountered with living very low carb/ketogenic over years
Ketosis in a Nutshell – Part 5, A Hunger Haven (itsthesatiety.com)
Ketosis in a Nutshell – Part 6, A Hungry Man (itsthesatiety.com)

(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.

his story http://www.eatlowcarbhighfat.com/?page_id=7

(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:

Jimmy Moore’s blog http://livinlavidalowcarb.com/blog/
Dr. Andreas Eenfeldt’s blog www.dietdoctor.com
Dr. Jeffry Gerber’s blog http://denversdietdoctor.com/dr-jeffs-blog/
my blog http://www.myketohaven,com is intended to be a place to collect stories. I have only recently set this up and I hope to get more posted on it once I get another few posts done that I have been trying to get to.
I am sure other people will post and collect stories as well.

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

Ketosis in a Nutshell – Part 1, What’s Up? (itsthesatiety.com)
Ketosis in a Nutshell – Part 2, Crazy Little Things (itsthesatiety.com)
Ketosis in a Nutshell – Part 3, Happy Campers Galore (itsthesatiety.com)
Ketosis in a Nutshell – Part 5, A Hunger Haven (itsthesatiety.com)
Ketosis in a Nutshell – Part 6, A Hungry Man (itsthesatiety.com)

Ketosis in a Nutshell – Part 3, Happy Campers Galore

Posted on October 10, 2012 by Dr Dea Roberts MD

the best part of whipped cream (Photo credit: thepinkpeppercorn)

Many people find that they are pleased (joyful even) to have the option of making use of nutritional ketosis to help them improve their health.

(terminology list at bottom of Part 1)

The numbers of those people are growing steadily as barriers to use of ketogenic diets fall:

in the neurological community, the diets have gone from being perceived as too onerous to use in all but rare cases – - to – - progressively becoming more practical and more palatable
in the weight loss community, use of nutritional ketosis has gone from often being perceived as an overly strict diet that a person will often “blow” and not use long term - – to – - being much better understood and developed into an eating style that many have adopted over many years with sustained health benefits
in both communities, people have gone from a situation with lack of support at the community and peer level – - to – - LOTS of peer support is now available online and in other forms
the day-to-day experience of the foods and the meals is much enhanced by the many recipe sources and “foodie” sites online
people are able to share their positive experiences with nutritional ketosis and network this information online
people are able to share their negative experiences with nutritional ketosis online and get trouble-shooting support
continued experience and research has shown that, while there is potential for side effects and there are certain cautions to keep in mind, with proper instruction in a nutritionally sound eating pattern and a reasonable degree of medical support, over-all nutritional ketosis can be used safely over time (with more intensive supervision needed for the stricter versions of the diet, for younger children, for people with more medical problems and medications – particularly during the transition phase)
particularly, one of the most important barriers has been concern over the safety of the very high fat intake that is an absolute requirement for long term use of nutritional ketosis. Reams and reams and web page after web page have been written on this topic and I am not going to attempt a review of it here. Research done on people following a ketogenic or very low carbohydrate diet in a clinical or research setting (and thus having received some instruction, support and lab monitoring) have not born out these concerns – although monitoring is important to spot the relatively small number of people who do not do well on such a diet. Also, considerable doubt has been thrown on the concept that there exists any scientific evidence of harm from a high fat diet – at least in the absence of high glucose or a moderate or high carbohydrate intake (other than in those with specific genetic susceptibility). The research has not separated out the impact of high fat from the impacts of glucose loads.

The availability of home blood ketone test meters and better understanding of their use is likely to substantially speed up the expansion in the use of nutritional ketosis (ketogenic diets) as it will likely help people achieve benefits more reliably and with less confusion and effort.

The Nutritional Ketosis “Nation” Comes from Two Founding Peoples:

(1) Ketosis for control of epilepsy in children

(2) Ketosis for weight loss

Nutritional Ketosis (ketogenic diet) for Epilepsy Control

for wonderful stories and pictures of people who have had dramatic recovery of their health from using a ketogenic diet for epilepsy control see HERE. This is a page of personal stories on the website of The Charlie Foundation. Most of the stories are of kids, but some are reports by adults of their recovery with the diet when they were children.
more happy stories on the website of the U.K. organization Mathew’s Friends. On their home page, click on About Us and then on Our Stories.

Short version

Although remarkably effective for many patients, the ketogenic diet for epilepsy control fell into obscurity as more and more medications, as well as surgical options, came into use. It was remembered the way it was in the early decades of use - suitable for a very small number of people, requiring a specialised team and hospitalization to undertake, being very challenging and unpleasant, and presenting medical side-effects and potential nutritional compromise, such as growth restriction. Time has brought much progress, though. Now, not only is the “classic” version of the diet much easier and more pleasant than it was in the 1920′s and 1930′s when it was first in use, but also there are less stringent versions of the diet as an option. In the past two decades, it is the pleased parents of the recovered kids who have pushed the medical community to play catch-up in recognizing this critical medical intervention. Clinical use continues to rapidly expand around the world and researchers are expanding the horizons of the potential uses of ketogenic diets in medical care.

Longer version

It was in the 1920′s that the “classic” form of the ketogenic diet was developed and first used for epilepsy. They knew that sometimes people with epilepsy would improve during periods of fasting or starvation. Trouble is, they didn’t know what it was about starvation that caused this improvement – or if it was due to a combination of factors. They knew that the level of ketones went up during starvation and they knew that there also tended to be dehydration. Also, in starvation there were not the nutrients to allow for growth.

The diet plans were being developed to try to help with children who were in very serious and difficult medical circumstances. These children had severe epilepsy that was not responding to other medical treatments. For this reason, the most effective diet plan possible was the goal. The “classic” ketogenic diet involved all three of these factors combined together.*

The diets were designed for the highest promotion of ketone levels in the blood – meaning the least protein compatible with health, tiny amounts of carbohydrates, and the rest as fat – all measured exactly. They were trying to mimic starvation as closely as possible.
There was a limit placed on fluid intake – both the total amount per day and the amount at one time.
In addition, the diets were designed with precision to give the children substantially fewer calories per day than the standard calculations said they needed – in fact, only 75% of their calculated needs. The plan was that a child would not lose or gain a pound (despite the fact that normally children grow). The children were weighed often (e.g. monthly). If the child lost or gained any weight, the food allotment would be adjusted up or down to correct for this.

These diets were dramatically beneficial for many of the children. Still, some did not benefit and some had partial improvement. The most remarkable finding was that some children, if they had excellent seizure control, could return to a full normal diet after a couple of years without the seizures coming back.. They were effectively cured of their epilepsy. Given that the stakes were so high, the degree of response was frustratingly unpredictable. It could also be erratic – sometimes a child who had been doing well would have a brief recurrence of seizures for no identifiable reason. Sometimes the seizures returned and no adjustment in diet could be found that resulted in regaining seizure control. The seriousness of the situation, the great hope for improving the lives of these children, the unpredictable and sometimes erratic nature of the response and the lack of helpful insights from research or lab tests all combined together to make it difficult to stray from the “tried and true” version of the diet plans. The diet plans required intensive highly expert supervision and were extraordinarily stringent, difficult and nutritionally tenuous.

It isn’t hard to understand why the use of the ketogenic diet for epilepsy control fell into obscurity as more and more prescription medications for seizure control were developed - along with more surgical options. It languished for decades. Where it did remain in use, by a dedicated team at John Hopkins, the passing decades brought substantial improvements in the practical application of the diet. A big reason for the diet becoming easier and more pleasant to use was the fact that tables of the detailed nutrient content of all common foods became available, which was not the case in the 1920′s. This, along with home use of highly accurate food scales, enabled the design of diets composed of a greater variety of normal household foods. Still, the implications of these developments went un-noticed by the greater medical community.

It was the parents who changed all that. The hospital team kept the knowledge alive and developed it to a more usable form. It was the parents who insisted (INSISTED) on spreading the word about the life-altering potential of the ketogenic diet. Why the enthusiasm for a dietary treatment that still, despite the improvements, was still difficult and a serious medical intervention? Many children continue to suffer from severe epilepsy despite being tried on any number of medications, medications in combination and despite the availability of improvements in surgical options.

In the early 1990s, the desperation of the situation these children and families faced led to a resurgence of interest in the ketogenic diet. With The Charlie Foundation and Mathew’s Friends anchoring the voices from the parents’ and patients’ side, the medical community has scrambled to keep up as demand for and use of the ketogenic diet has rapidly expanded, now world-wide. (It only sounds like hyperbole because it is such a good story.)

Recently, doctors were very surprised to serendipitously find that a much less strict version of a ketogenic diet (rather than the “classic Ketogenic Diet”) could be very effective for some people for epilepsy control. This finding led to the development of a specific dietary program called the “Modified Atkins Diet”. It is very much like the classic Atkins Diet, but with some tweaking to make it more steady in its effects.

Another more liberal version of the diet was developed in 2002 based on the Glycemic Index. This is a diet that keeps total carbohydrates low (not as low as the above two versions), but also focuses on the quality of the carbohydrate foods chosen. It incorporates carbohydrate foods that are slow to digest – meaning that the glucose from the food is absorbed from the digestive tract slowly. Refined sugars and high GI starches are avoided.

Other diet variations are the MCT Ketogenic Diet, which incorporates MCT oil, and the Modified Ketogenic Diet.

There is one confusing aspect to the terminology about the diets. The use of ketogenic diets for epilepsy has evolved, until recently, as its own little insular world. There were no other deliberate medical uses of ketosis in the early decades. Neurologists got used to using the term “Ketogenic Diet” to describe the very specific highly regularized diet program they were using (including fluid restriction, 75% calories with normal weight children, three meals of identical nutrient balance, etc). Why not? No one else was using the term. Now this causes some confusion as, of course, this is just one possible version of “a” ketogenic diet (a sustainable eating pattern that causes the development of ketosis). It is helpful to refer to this as the “classic Ketogenic Diet” or “Classic Ketogenic Diet”. Unfortunately, those in the epilepsy diet community are so used to using these terms (and so often are speaking to each other and implicitly know what each other means) that often the term “classic” is left off. This can cause some confusion. Also there seems to have been some lack of understanding as it seems that at least some in the neurological community did not understand that the Atkins Diet was intentionally designed to promote the development of ketosis in the early stages – to take advantage of the known appetite suppressing effects of ketosis (ref – Atkins 1973 book, see next installment of this series).

The more acceptable the diets become, the more reason researchers have to delve into the science of what is going on in the body in response to the diets and what other medical conditions might benefit from the use of ketogenic diets. We still don’t know exactly how these diets cause their beneficial effects. It is clear that not everybody needs the same combination of diet mechanisms to achieve similar levels of benefit – that is, some people need stricter, more ketotic diets and others do as well with less strict diets. (For more details on the research, see some of the medical papers listed (with links) at the bottom of Part 2 of this series.)

To reflect the new understandings, a term now being used is “Metabolic Therapy”, which incorporates the idea that there are a number of ways to manipulate metabolism that may be harnessed for treatment of neurological conditions.

To see videos of a one day conference in Toronto, March 2010, about dietary treatment of epilepsy, including the various diet options and the treatment of adolescents and adults, please visit my web page HERE

Nutritional Ketosis for Weight Control ….. to be continued next installment

* some of the core Ketogenic Diet principles detailed in the 1996 book “The Epilepsy Diet Treatment: An Introduction to The Ketogenic Diet, 2nd edition” by John M. Freeman, M.D., Millicent T. Kelly, R.D., L.D. and Jennifer B. Freeman of the John Hopkins Pediatric Epilepsy Center.

Meryl Streep supports epilepsy charity event (sfgate.com)
Ketosis in a Nutshell – Part 1, What’s Up? (itsthesatiety.com)
Ketosis in a Nutshell – Part 2, Crazy Little Things (itsthesatiety.com)
Ketosis in a Nutshell – Part 4, Happy Campers More (itsthesatiety.com)
Ketosis in a Nutshell – Part 5, A Hunger Haven (itsthesatiety.com)
Ketosis in a Nutshell – Part 6, A Hungry Man (itsthesatiety.com)

Other Resources:

The Charlie Foundation – an American organization that has played a central role in the resurgence over the past 2 decades in the use of the ketogenic diet for epilepsy control. The web site offers extensive information. www.charliefoundation.org

“The Charlie Foundation was established in 1994 in order to raise awareness about the ketogenic diet as a treatment for childhood epilepsy. The modern success of the diet has led to new demands on the medical community. In order to meet these demands, the Charlie Foundation has expanded its priorities to include educational programs for dietitians and neurologists as well as support for clinicians and researchers working to perfect its administration and discover its mechanisms.”

Mathew’s Friends – an organization in the U.K. that similarly plays a central role in providing information and supporting access to treatment. Extensive information is available on their website. http://www.matthewsfriends.org/

Books oriented to the dietary control of epilepsy:

The Keto Cookbook: Innovative Delicious Meals for Staying on the Ketogenic Diet

Ketogenic Diets: Treatments for Epilepsy and Other Disorders

Dietary Treatment of Epilepsy: Practical Implementation of Ketogenic Therapy

Fighting Back with Fat: A Parent’s Guide to Battling Epilepsy Through the Ketogenic Diet and Modified Atkins Diet

Ketosis in a Nutshell – Part 1, What’s Up?

Posted on September 25, 2012 by Dr Dea Roberts MD

- - an inside joke – macadamia nuts are popular among those seeking ketosis.

We Newly Have Practical Access to a Potentially Major Health Intervention

CLUNK - – Click, click … whirrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr …….

The recent adoption of home testing of blood ketones as a tool in the use of nutritional ketosis is like a missing gear being dropped into place. Many streams of knowledge and progress are brought together in a new and newly workable way.

Ketosis and Nutritional Ketosis – What is this?

You can learn to eat in a way that causes you to burn a lot of fat while burning low amounts of glucose. In the process, your liver will produce ketones, these will travel in your blood stream (ketosis) and be burned for energy. You have altered your “nutrition” to be in a state of “ketosis” – thus the term “nutritional ketosis”. This is also referred to as eating a “ketogenic diet”. When you do this over time, you gradually become more adapted to functioning in this state. This is called being “keto-adapted”.

This is all entirely different from diabetic ketoacidosis, which is a very serious medical emergency that can develop very rapidly and is potentially fatal. Ketoacidosis is precipitated by dehydration in the context of insulin deficiency. A person who is not deficient in insulin function will not develop ketoacidosis.

It seems to be talked about a lot recently. Why the buzz?

This is an eating strategy that can act as powerfully as a medication.

This eating strategy may improve your sense of well-being and physical performance.

It may be useful in many more situations, involving many more people, than we thought.

It has now become much more practical to use as a long-term choice than we thought.

Known and Potential Uses:

(1) Medical

When considering what we know of nutritional ketosis, plus what new insights and research suggest, nutritional ketosis has or may have a substantial role to play in:

blood sugar control
management of metabolic syndrome
visceral fat control
obesity
appetite control
epilepsy, in both children and adults
Alzheimer’s Disease and some other neurological conditions
and what others unknown?

(2) General Well-Being

Besides the above, many people who have become keto-adapted report that they just feel a lot better over-all. Many report improved energy levels, mood or mental clarity.

(3) High Performance

Beyond that, being in nutritional ketosis can mean improved physical performance, particularly in endurance activities. Competitive athletes are making use of this.

Great – But is it Usable? Is it Practical Long Term?

The key to unlocking the great potential for benefit is that nutritional ketosis must be a realistic, practical option for long-term use. This has been the major block. Why consider it as an option for people to use if it just seems to be much more of a burden that a help? Why do a lot of research about something that won’t be used? It must be worthwhile – the benefits must be worth the “costs” in effort, limitations, risks, etc.

The key criticism of ketogenic diets and thus of the use of nutritional ketosis as a health tool or medical treatment has been that they are “too difficult” and not worthwhile over time.

(1) Poor testing options mean we have not been able to accurately assess either long term benefits or long term practicality.

A “ketone” is a type of molecule, not just one molecule. However, the tests measure just one of the types of ketone molecules that the body produces when in ketosis.

Until recently, the only test for ketosis that could be used day-to-day at home was urine test strips. Blood ketone testing could be done at a medical lab, but this was too expensive and awkward for routine use. The trouble is, urine test strips are not very useful for monitoring the level of ketosis once a person has become adapted over weeks to being in ketosis.

The reason ketone test strips were developed and marketed is so people with diabetes can test themselves for ketones and so have early warning if they are headed for ketoacidosis and need to seek urgent medical attention. The urine strips test for a molecule called acetoacetate, which shows up in the urine right away when someone is just going into ketosis or has been in ketosis a short time. For diabetics, this works very well and is a cheap, convenient test (at least, for those people with diabetes who are not chronically in low-level ketosis from choosing to eat in a way to be in nutritional ketosis).

When people eat in a way to develop ketosis, the body adapts to this. Part of this adaptation is that the metabolism of the various ketone molecules changes. The level of acetoacetate molecules go down, so that, for example, the person can be in a low level of ketosis and yet this might not show on a urine test strip. In this situation, use of blood ketone testing provides much better information. Blood ketone home monitors test for a different ketone molecule called beta-hydroxybutyrate.

Blood ketone home monitors have been available for a while, but have been little known outside of the field of diabetes and even then, not widely used. Their potential role as a tool in the use of nutritional ketosis has only recently arisen as a topic.

The particular trigger for this was the publication in April 2012 of the influential book The Art and Science of Low Carbohydrate Performance by Jeff S. Volek, PhD, RD and Stephen D. Phinney, MD, PhD. Subsequently, awareness and interest in the topic has surged in the wake of the reports by Jimmy Moore of the very widely followed blog Livin” La Vida Low Carb, detailing of his personal experiences with using blood ketone testing. Jimmy Moore’s n=1 Experiments: Nutritional Ketosis Day 91-120

(To be fair, I should acknowledge that the first mention I saw of blood ketone testing meters was on Dr. Peter Attia’s site in March 2012.)

(2) Any medical treatment that cannot be well monitored or adapted to the individual over time will always appear less effective and more burdensome than it truly need be.

It may be that the benefits of nutritional ketosis have been masked by lack of ability to monitor or target the degree of ketosis properly for individual tolerance and benefit. That is, perhaps the lack of good testing options has meant that the way ketosis has been used has made that it appear less effective than it really can be and, at the same time, more difficult or burdensome to live with than need be.

Deliberately eating in a way to cause ketosis has basically been used in two ways:

as a medical treatment for epilepsy, in which extremely strict diets were used
as part of a low carbohydrate weight control plan (Atkins Diet), of which ketosis is a major tenant. The lack of ability to accurately test to see if a person stays in ketosis over time, and the degree of ketosis, has likely been a source of confusion and inconsistency – likely major factors in the degree of variability in people’s responses and how people do over time.

(3) Blood ketone testing brings individuals a better chance of finding lasting benefit.

Consider a person who has benefits from being in sustained ketosis (being keto-adapted). If that person is going in and out of ketosis or having wide fluctuations in their degree of ketosis, those benefits will come and go in confusing, unpredictable ways. In this case they may well find that the efforts and costs (things they give up, changes in their life, any side-effects and risks, etc.) are not worthwhile over time. If they choose to abandon their efforts to be in ketosis, they then get zero benefits.

If they can use home testing of whether they are in ketosis and the degree of ketosis, they can use this to more accurately perceive any benefits. With more effort and time they can get a reasonable idea of what level of ketosis is associated with what degree of benefit. In terms of the costs, they will have realized what eating patterns or other factors are required for them to be able to be in ketosis or at certain levels of ketosis. From experience, that person can begin to form a judgement of what the balance of benefit versus cost is for them. There is a better chance that they may find at least some level of benefit that they are able to enjoy long term because they are able to choose a level of costs that they personally find worthwhile.

The benefits a person can notice for themselves will often be only part of the story. Assessment by their physician, possibly including lab tests and other investigations, is a necessary part of considering what the benefits have been. Even then, some of the benefits may be difficult to evaluate and some may be slow to develop and only evident over years.

Similarly, it is dangerous and unwise to assume that the harms and burdens a person notices themselves are the whole picture. Again, assessment by a physician, possibly including lab tests and other investigations, is a necessary part of considering what harms there have been and what the ongoing risks are. Even then, there may be unrecognized or hidden harms that do not become evident until some years later

(4) Blood ketone testing will open up progress in understanding and research.

People can communicate with each other and with their health providers much more effectively about their experiences with nutritional ketosis. Researchers can target new questions and new areas of potential benefit.

For example, many research studies have been done to evaluate the benefits of low carbohydrate diets. Yet, none of them have used monitoring of blood ketone levels as a tool to evaluate the presence or depth or variability of nutritional ketosis despite the fact that it is one of the key proposed beneficial mechanisms of low carbohydrate programs. (** see addendum below for correction) Again, consider the fact that if a person is unknowingly moving in and out of ketosis they are likely to find this very disruptive and un-satisfactory, which could well lead to abandonment of the intended eating plan and a perception that it is not worthwhile.

So, There is Promise – What are the Risks or Concerns?

We are in the early stages of understanding about nutritional ketosis and how this might be useful for general well-being or medical purposes. The potential for benefit seems to be large.

What we already know for sure is that some people’s bodies seem to adapt well to ketosis and some people’s do not. There are some people for whom nutritional ketosis is not suitable.

We need to learn much more about possible side-effects and potential for harm, especially long-term. We do already know about some side-effects and harms that can develop that we need to be cautious about – for example dehydration, exaggerated medication effects and serious problems with sodium and potassium. There is considerable potential for harm from un-recognized long-term deficiencies of essential nutrients, as feeling “full” does not in any way mean that one is well “filled” with the essential vitamins and minerals.

As with everything else in health and medicine, there is wide variation between people in the benefits and the harms that any individual may personally experience.

The trade-offs and cautions and risks (an incomplete list):

this requires following a very specific eating pattern, and this needs to be learned
that eating pattern needs to be consistent over time, with little use of “breaks” or “holidays” from the eating pattern
it takes a while for your body to adapt to using ketones for fuel and, until then, you may have side-effects and feel tired or unwell
you will be more susceptible to dehydration, to low blood sugar, and to potentially serious problems with the “electrolytes” sodium, potassium, calcium and magnesium. If you don’t take the time and effort to learn about these things,and are not prepared to be disciplined about them, do not consider proceeding. Beyond that, there are medical conditions and medications and herbal (and other) therapies that can mean you are even more susceptible to these problems, and these must be considered. Nutritional ketosis is not appropriate in all situations.
there are certain situations or medical conditions that would mean that you should not use nutritional ketosis (or should do so only with knowledgable professional help). One particularly critical consideration is that there are certain medications that may need to be changed or doses adjusted before starting and possibly at frequent intervals in the first days, weeks and months.
you will need to put some time and effort into learning how to not harm yourself with poor nutrition while eating this way. Feeling full does not in any way mean that your full nutrient requirements are being met. Poor nutrition can be hidden and not produce warning signals that are obvious or easily understood. Our ability to monitor with lab tests how well you are stocked with the many essential vitamins and minerals is remarkably poor.
children and pregnant women require special consideration beyond the scope of this article.

This is an incomplete list. Even 5 years from now, it will not be possible for anyone to produce a complete list. The full risks of harm from nutritional ketosis, especially over a prolonged time, are not known. Have caution.

**********************************

** Addendum Sep 29/12 – Touched by an Angel – Thank-you to Jenny Ruhl for gently pointing out my carelessness in this paragraph. What I wrote was not correct as stated and what I wrote did not match very closely what I was trying to express. I’ll take another stab at it. – Many studies have been done to investigate the usefulness of the “low carb diet” approach to weight loss. These fall into two types. One type of study is basic research – “what can we demonstrate happens when we carefully do “x”". “How does the body respond under these circumstances?” They are done on relatively small numbers of people and under close supervision.

The other type of study is designed to see how useful the intervention “x” proves to be in larger numbers of people in something closer to a real-world situation – this intervention “x” may have certain effects on the body, but is it useful under practical circumstances? When you offer this to people, do the benefits play out as expected? As part of this – do people continue with the intervention or do they abandon it for one reason or another? As it turns out, generally in these larger studies there are many people who do not follow the low carb eating plan as instructed for very long into the study period.

These results form a major justification for the continued claim and perception that “low carb diets” may be theoretically useful but fail in the long run, and they fail specifically because people find they are not able to stay with the diet plan.

“Low carbohydrate diets” are not necessarily ketogenic diets, although they may be, and this causes confusion and error. From what I recall, the emphasis in these larger studies is on the “low carb intake” rather than on the “dietary ketosis” itself. If you go back to Dr. Atkins’ 1972 book, he strongly emphasized the critical role of ketosis, with low carb being the means to that end. Then you have to ask yourself, what is being tested? I think the question has been muddied, which, if so, would certainly compromise the usefulness of the research results. In research, it is all about the question. If people aren’t taught that ketosis is the central target, how to be in ketosis and then adequately supported in understanding, trouble-shooting and individualizing their lifestyle/health/diet program to optimize their ability to attain and maintain ketosis, then what is being tested may be any manner of other useful questions about various degrees of limitation of carbs in the diet, but the results of the study will have no meaning towards questions about dietary ketosis. Having people do urine ketone testing may or may not represent this level of focus and support.

For example, the description of the low carb diet used in the 2008 study published in the New England Journal of Medicine, in which they did use urine ketone testing:

“This low-carb, non-calorie restricted diet aimed to provide 20g/day of carbohydrates during the induction phase (first 2 months), and returned to this level of severe carb restriction after each religious holiday. At other times participants were instructed to increase carbs gradually up to maximum of 120g/day to maintain the weight loss. Total calories, protein and fat intake from any source (except industrial -trans fats) were not limited.”

This is a brief summary of the “low carb diet” used in this study:

Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.

Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I, Golan R, Fraser D, Bolotin A, Vardi H, Tangi-Rozental O, Zuk-Ramot R, Sarusi B, Brickner D, Schwartz Z, Sheiner E, Marko R, Katorza E, Thiery J, Fiedler GM, Blüher M, Stumvoll M, Stampfer MJ; Dietary Intervention Randomized Controlled Trial (DIRECT) Group.

N Engl J Med. 2008 Jul 17;359(3):229-41. Erratum in: N Engl J Med. 2009 Dec 31;361(27):2681.

PMID: 18635428 Free Article

They were testing a more liberal version of the “Atkins diet”, which is a perfectly valid thing to do. There are many aspects of the whole ball of wax referred to loosely as “low carb” that are in need of study. They were not trying to study ketosis and they did not claim to have learned anything about the value or effects of sustained ketosis. In the full text, they only report the urine ketone level at baseline (pre-diet) and at 24 months. I don’t see any mention of urine ketone testing at any other time or of the participants using at-home urine ketone testing as a way to monitor whether they are in ketosis or as a way to prompt any changes in what they are doing. Of course, a part of the reason for this may be the awareness of the imprecision of urine ketone testing in milder states of ketosis once a period of adaptation to ketosis has passed.

Given that they are reporting on their results with a “low carbohydrate diet”, even though they did not study ketosis, the results may be mis-interpreted as applying to sustained ketosis.

If people are unknowingly and inconsistently moving in and out of ketosis, it would be expected that they would experience the appearance and disappearance of both welcome effects and unwelcome side-effects. It would be expected, in that circumstance, for weight and appetite and energy levels to fluctuate widely. This could be expected to be very discouraging and result in many people abandoning the diet. The sudden jump in hunger when moving out of ketosis would often lead to even greater food intake, putting the person firmly out of ketosis. Carbohydrate craving in this circumstance can simply be a sign of moving out of ketosis, but, without proper education and awareness about ketosis, is likely to always be interpreted as an emotional desire for carbs or as “missing them” too much (which can also happen).

I hope that the increase generally in research and interest related to ketosis, along with the availability of home blood ketone meters, will lead to :

a clearer framing of the question and study design, taking the above into consideration – are they studying ketosis or not
if they are NOT studying ketosis, a recognition of the importance of a study design that does not ignore the possible confounding factor of ketosis
if they are proposing to be studying ketosis, or Dr. Atkins’ original claims, a recognition that teaching the study participants a “low carb diet” or “very low carb diet” and having it “sort of” followed is not any longer an acceptable proxy for studying a “ketogenic diet”

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To be continued …. Part 2

Important Note: This article is written to promote discussion. It is not intended to be medical advice. It is not intended to promote the use of a ketogenic diet or nutritional ketosis by any specific individual. Any person who would like to consider the use of a ketogenic diet or nutritional ketosis should first seek the advice of their personal physician. This article is an overview and does not provide enough information for anyone to use for clinical decision-making.

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The Terms

“Ketosis” means there are “ketones” in your blood. People have at least a very small amount of ketones in their blood all the time. Generally, the word “ketosis” is only used when the ketones are more than just the usual very low day-to-day background level.

“Ketones” are a type of molecule you produce in your metabolism. They are produced in the liver during the breakdown of fat molecules. These ketones do not show up in the blood at more than trace levels unless there is a lot of fat being broken down in the presence of low supplies of glucose. Insulin stops the production of more than trace amounts of ketones, and insulin levels are higher with increasing amounts of glucose. Ketones are a valuable fuel molecule and an essential part of our metabolism. They are not directly harmful in any way except if they reach extremely high levels, which can only happen in diabetes (see “ketoacidosis”).

Ketones can be used for fuel by almost all the organs and cells of the body. One of the especially important things about them is that they are the only fuel besides glucose that the brain can use. The brain uses ketones for a fuel very readily, but ketones can not be used in all the ways that the brain uses glucose, so there is always a need for an adequate, normal level of blood glucose (some other cells also need glucose, such as the retina and the red blood cells).

“Ketone bodies” – In chemistry, there are many, many molecules that are of the type classed as ketones. When we refer to “ketones” in your body, by common usage we are specifically meaning three molecules named acetoacetate, acetone and beta-hydroxybutyrate. Technically beta-hydroxybutyrate does not fit the definition for ketones. Functionally, beta-hydroxybutyrate acts like a ketone in that it can readily be metabolized back to acetoacetate, thus acting as sort of a transit or storage form of ketones. The term “ketone bodies” is useful in that it has been used as a catch-all phrase to refer to these specific three molecules (one of which is a ketone supplier, rather than a ketone itself). (Note: this description amended Sep 29/12)

“Ketoacidosis” is a very serious, potentially fatal condition that can occur in people with diabetes. Having insulin in the blood to stops ketones from going very high, so people who produce enough of their own insulin will not develop very high ketone levels no matter how they change their food intake. Even people in starvation do not get ketoacidosis (unless they are diabetic).

“Nutritional ketosis” or “dietary ketosis” means that, because of what you have or haven’t eaten, your body is making more of the type of molecule called “ketones”. This distinguishes ketosis caused by reasons outside the body from ketosis produced by abnormal function of the body (deficiency of insulin).

“Depth of ketosis” or “degree of ketosis” refers to how much the level of ketones in the blood rises. You are “deeper in ketosis” as your blood level rises higher.

“Keto-adaptation” is a term coined by researcher Dr. Stephen Phinney M.D. to refer to the fact that it takes some weeks and up to 2-3 months for a person’s body to fully adapt to functioning in a state of nutritional ketosis. That is, to become adapted to using fats and ketones as the predominant fuel, instead of the usual situation, where glucose is used as the predominant fuel. Part of keto-adaptation is that there is a normal, steady blood level of glucose, with the glucose coming mostly from sources within the body, rather than coming mostly from the digestion and absorption of glucose from food.

Ketosis in a Nutshell – Part 2, Crazy Little Things (itsthesatiety.com)
Ketosis in a Nutshell – Part 3, Happy Campers Galore (itsthesatiety.com)
Ketosis in a Nutshell – Part 4, Happy Campers More (itsthesatiety.com)
Ketosis in a Nutshell – Part 5, A Hunger Haven (itsthesatiety.com)
Ketosis in a Nutshell – Part 6, A Hungry Man (itsthesatiety.com)

Celiac disease limiting fuel for endurance – keto-adaptation would solve that!

Posted on June 3, 2012 by Dr Dea Roberts MD

Nutritional Ketosis as an Effective Strategy for Fueling Endurance

From New Zealand comes this report of an ultra-endurance athlete who had difficulty meeting fuel needs.

One solution for this would be the strategic use of nutritional ketosis. To use this strategy, the athlete needs to be metabolically adapted to burning ketones for fuel. This means being in nutritional ketosis for at least some weeks before the race day. The term that is used is “being in a state of keto-adaptation“. The advantage is that during the endurance exercise, the body can draw on the vast calories stored as fat (even in very slim people), while using less of the glycogen stores.

Int J Sport Nutr Exerc Metab. 2012 May 10.

Case Study: Nutritional Strategies of a Cyclist with Celiac Disease During an Ultra-endurance Cycle Race.

Black KE, Skidmore P, Brown RC.

Department of Human Nutrition, University of Otago, Dunedin, New Zealand.

Abstract

Food intolerance is becoming increasingly prevalent and increasing numbers of athletes participating in sporting events have celiac disease. This poses challenges as dietary recommendations for exercise are largely based on gluten containing carbohydrate-rich foods. The K4 cycle race covers 384 km around the Coromandel Peninsula, New Zealand. Lack of sleep, darkness and temperature variations pose a number of nutritional challenges. Limited food choices present those with celiac disease with even greater challenges. This case study describes the intakes of one such athlete during training and competing in the K4. Nutritional intakes were obtained during training using weighed food records and during the race via dietary recall and the weighing of foods pre- and post- race. As simple substitution of gluten containing foods for gluten-free foods leads to increased energy intake, alternatives need to be considered. During the race, insufficient energy was consumed to meet the nutritional guidelines for endurance performance. This was probably due to the nature of the course, racing conditions, the consistency of gluten-free food, and towards the end of the race, sensory specific satiety. PMID: 22645170

To go to the font of the scientific knowledge on this, the book to read about the use of nutritional ketosis as a strategy for athletic performance is The Art and Science of Low Carbohydrate Performance by Jeff S. Volek, PhD, RD and Stephen D. Phinney, MD, PhD. The price is more than reasonable ($8.95 on amazon and no I have absolutely no commercial ties or links).

it's the satiety

first solve the hunger, then consider weight

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Celiac disease limiting fuel for endurance – keto-adaptation would solve that!

Case Study: Nutritional Strategies of a Cyclist with Celiac Disease During an Ultra-endurance Cycle Race.

Abstract

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Case Study: Nutritional Strategies of a Cyclist with Celiac Disease During an Ultra-endurance Cycle Race.

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