A few years ago, my family and I set out to build a pond.
I have always loved Koi and the serenity of a Koi pond in my own back yard was very enticing. I spent about a year planning my design and the location. I dreamed of a serene evening after a very long, hectic day seeing patients relaxing beside the pond. The sound of trickling water, the occasional splash from fish, the cool breeze passing over the mist from a water-fall would sooth my soul after a busy day in the office.
I envisioned the perfect area. An unused access path, previously worn by the previous owner with truck and trailer traffic, beside my now expanded patio. Twenty feet wide, thirty feet long and four feet deep. . . that seems just perfect.
I pulled out my shovel and set about digging. Eager to begin and filled with the energy of the final product, I set to digging. What could be so hard about digging my own pond? Think of the exercise I will be getting. Thoughts spurred me on.
Minutes later, chest heaving, face glistening with sweat, I stared in dismay at the ground. All I had to show for my wild digging was a small 1/2 inch dent in the dusty Arizona top soil.
Sonoran Clay
Over time, calcium-carbonate, along with other minerals, accumulates and dissolves into the topsoil of the very arid regions of Arizona Sonoran Desert. It forms a two to three-foot layer of soil called “caliche.” Periodic rains carry the calcium as far as three feet down into the soil, then the water rapidly evaporates in the blistering Arizona heat. This often forms two to three feet of soil that is “literally” harder than concrete.
With tremendous zeal, a great deal of sweat and a round of painful blisters, I broke my third shovel on this impenetrable ground. I realized this was much more difficult than I thought. I pulled out the back-hoe attachment for my small farm tractor. After a few hours and few gallons of diesel fuel later, still very little progress occurred.
Multiple weekends and evenings of digging in the Arizona caliche left me with three broken shovels, a ruptured hydrolic line in my tractor, anger that my expensive back-hoe attachment didn’t work, and only a small dent in the ground near my patio. Even the brute force from the tractor would not budge the clay. I wondered if dynamite would be effective? (My wife would have none of this idea).
With my exuberance quashed, I concluded that this would require much more measured exhuming.
Escape From the Prison
We often imagine, with great delight, the removal or destruction of that which enslaves or imprisons us. We dream that just a little sweat, exertion of a few shovel scoops of dirt and the foundation to our prison of obesity, addiction, debt, and depression are exposed. A few extra scoops and we imagine freedom from that prison cell.
If only I had a jack hammer and a bigger, more powerful scoop, I imagine . . . I could make short work of these manacles that bind me.
But, our manacles and prison cells do not so easily give way.
The failings of our sharpened spades and powerful back-hoes form a new, even stronger fetter – the belief that our prison cell is unbreakable, that our challenge is just too great. These failings usually leave a person cured of any further desire to break free. It quashs the dream and solidifying the depression of stagnation.
The in-fecundity of my shovel, no matter the strength and effort put behind it, was not cause to quit. It was life’s lesson that prisons and shackles often only need a simple tool.
Enter the pick-axe. During this process my wife said, “Honey, why don’t you use the pick in the garage?”
“If my shovel and the back-hoe didn’t work, there was no way I was going to break through this clay with a pick axe.” That was absurd, I thought.
Yet when I humbled myself to try, it was simple. The pick-axe was unpretentious. This simple tool allowed for an almost effortless stroke to a small area of weakness in the caliche. A large flake of soil would pop free with each stroke. The process was repeated.
Scale by scale, the dragon’s flank was exposed. Careful work of the pick-axe began to loosen layer after layer, section after section, pellicle after pellicle. Yes, it was slow work. But, each swing was a small victory.
At each little victory, my heart would leap, the dream would become ever clearer.
Working this magic again and again until finally the specter was weakened enough to pull out the shovel. And, further work, allowed for bringing back the powerful back-hoe, in gratifying scoops.
The excavation that I thought would take two months took me fourteen. But, it was gratifying.
I learned a powerful lesson. Wherever life has pinned you, fettered you or barred you in, put down the shovel, and pick up the pick-axe. Second, if you really listen, your spouse may point out the tool you really need. Don’t be afraid to chip away at it a piece at a time.
Finances
Stop waiting for the sharper shovel or the bigger back-hoe to dig yourself out of your harrowing debt, mega mortgage, or your income dwarfing spending. The jackpot or financial windfall won’t come. While others await the jackpot, put down your shovel and shoulder your pick-axe.
Pick one small debt and begin to pick at it by applying just a little extra each month until it is gone.
Cancel your extra cable, sell the motorcycle and payoff the 21% interest credit card.
If you must, pick up a side-hustle for extra to sharpen the pick.
Once you’ve lifted one flake, chip away at the next. Making progress will make it easier to continue. It doesn’t matter how long it takes, just keep at it.
Marriage
You long for resolution of the apathy, progressive resentment and mutual stalemate that permeates your relationship. You look in vain for the bigger shovel that will uncover the treasure that years of apathy have buried. You long to uncover your dreams and needs that have been covered and hardened under the clay of resentment. The shovel and the back-hoe won’t help you here.
Drop the shovel. Shoulder your pick-axe.
Kiss your wife every time you leave, even if it’s just for a ten minutes to run to the convenience store.
Hold her for five seconds longer every time you hug.
Find a gift you can give her once a week, just because.
Put down your phone and look her in the eyes when she talks to you and listen. Really listen and the flakes of hard clay will unveil the beauty of her soul.
Find a way to praise her every day, even if it is through a simple text.
Health
You long to rid yourself of your addiction to sugar, bread, stress, and sleep deprivation. You’ve tried to scoop them out of your life. You even hired a trainer with some muscle to force you to change. You’ve tried in vain to save yourself from yourself.
Trying to use the shovel here is like trying to use the shovel on steel forged walls of your life’s prison fortress. Forget the shovel. Shoulder your pick-axe.
Start with one meal and make some substitutions. My dietary plan can help you with this.
Go to bed an hour earlier. Really, you’ll be surprised that the focus you have will more than compensate for the hour of lost time in the evening.
Take ten minutes and do 20 push-ups and 20 sit-ups, then take a 10-minute walk.
Simply remove the “white stuff” from your meals. You will be amazed at the results.
Put down your phone for 30 minutes and read that book you’ve been meaning to read, instead of surfing Facebook.
Grand-standing with your back-hoe doesn’t help you. Just swing the pick-axe once or twice. Simple daily picking with the sharp point weakens the hardest of ground and the prison walls in our lives. It takes time, so be patient.
Find the weak point, apply the pick. Day by day, little by little you will be free.
I’ve been there. I’m with you. Keep me posted on your journey.
Over fifty years of data have demonstrated that creating energy deficit through the reduction in caloric intake is effective in reducing weight. . . However, it is only for the short term (1, 2). The biggest challenge physicians face in the treatment of obesity is that calorie restriction fails when it comes to long-term weight loss.
Isn’t Fasting Effective in Long-Term Weight Loss?
With the craze and popularity of intermittent fasting, some have claimed that intermittent fasting is more effective in weight reduction. Recent results demonstrate that this may also be incorrect. In the short term evaluation of caloric restriction and intermittent fasting, reduction in 15-20 lbs of weight is effectively seen and the highly publicized Biggest Loser’s losing ~ 120 lbs. Intermittent fasting and alternate day fasting have been shown to be more effective in lowering insulin levels and other inflammatory markers in the short term.
There is, however, controversy over maintaining weight loss beyond 12 months in the calorie restriction, intermittent and alternate day fasting groups. Forty different studies in a recent literature review, thirty-one of those studies looking at forms of intermittent fasting, demonstrate that the majority of people regain the weight within the first 12 months of attempting to maintain weight loss(3, 5). This is, also, what I have seen for over 18 years of medical practice.
Is Calorie Restriction the Only Way to Lose Fat?
Numerous “experts” claim that the only way to reduce fat is “caloric deficit.” Variations through the use of intermittent, long-term or alternate day fasts can be found all over the internet. In regards to calorie restriction, these “experts” with nothing more than a personal experience and a blog to back their claims preach this louder than the “televangelists” preach religion. Based on the faith that many place in this dogma, it could be a religion. What causes belief in this dogma is that weight and fat loss actually does occur with caloric restriction to a point. The average person will lose 20-25 lbs, however, within 12 months of achieving this goal, most people regain all the weight. (No one ever mentions the almost universal problem with long-term weight loss, especially those “experts.”)
Prolonged calorie restricted fasts, intermittent fasts, and alternate day fasts are often grouped together into the fasting approach, causing significant confusion among those that I speak to and counsel in my office. There is great data that alternate day fasts do not have the reduction in resting energy expenditure that prolonged fasting, intermittent fasting and calorie restriction cause. However, none of these approaches appears to solve the problem of weight re-gain after long-term (12-24 months into maintenance) weight loss (3). And, a recent study of 100 men participating in alternate day fasting showed that there was a 38% dropout rate, implying that without close supervision and direction, maintenance of this lifestyle is not feasible for over 1/3rd of those attempting it.
Long-Term Weight Loss Failure Brings Tears
Failure on calorie restricted diets, low fat diets, and intermittent fasting diets with weight regain at twelve to twenty-four months is the most common reason people end up in my office in tears. They’ve fasted, starved themselves, calorie restricted, tried every form of exercise, and still regained the weight. Trainers, coaches and “experts” have belittled them for “cheating” or just not keeping to the diet. Yet, we know that calorie restriction and intermittent fasting cause a rebound in leptin, amilyn, peptid YY, cholecystikinin, insulin, ghrelin, gastric inhibitory peptide and pancreatic poly peptide by twelve months causing ineffective long-term weight loss (6). The dramatic rise in these hormones stimulates tremendous hunger, especially from ghrelin and leptin.
N Eng J Med 27 Oct 2011. Mean (±SE) Fasting and Postprandial Levels of Ghrelin, Peptide YY, Amylin, and Cholecystokinin (CCK) at Baseline, 10 Weeks, and 62 Weeks.
Although less problematic in alternate day fasting, these calorie restricted approaches also cause dramatic slowing of the metabolism at the twelve month mark. In many cases, the metabolic rate never actually returns to baseline, creating even more difficulty in losing further weight or even maintaining weight (6).
N Engl J Med 27 Oct 2011. Mean changes is weight from 0 – 62 weeks.
Is Gastric Bypass or Gastric Sleeve the Solution?
Gastric bypass and the gastric sleeve procedures have been touted as the solution to this problem, as they decrease ghrelin, however, 5-10 years later, these patients are also back in my office. They find that 5-10 years after these procedures the weight returns, cholesterol and blood pressure rise, and diabetes returns. These hormones kick into high gear, stimulating hunger in the face of a slowed metabolism, that to date, has been the driver for weight regain in the majority of people. People find it nearly impossible to overcome the hunger. You may have experienced this, I know I have.
It’s the Hormones, Baby!
So, what is the answer? It’s the hormones. (WARNING – You’ll hear that when your wife is pregnant, too, gentlemen). We are hormonal beings, both in weight gain, and in pregnancy. Trying to preach calorie control to a hormonal being is like showing up at the brothel to baptize the staff. You might get them into the water, but you’re probably not getting them returning weekly to church or pay a tithe.
So, how do you manipulate the hormones in a way to control the rebounding hunger and suppression of metabolism? This is where we put a bit of twist on the knowledge we’ve gained from alternate day fasting. Recent research shows that “mild” energy deficit in a pulsatile manner, that has the ability to mimicking the body’s normal bio-rhythm’s is dramatically effective in reducing weight and maintaining normal hormonal function without cause of rebound metabolic slowing (4).
Pulsed Mild Energy Restriction
What does this mean in layman’s terms? It means that if we provide a diet that maintains satiety hormones while providing a period of baseline total energy expenditure needs and a period of mildly reduce caloric intake in a pulsed or cyclic manner, greater weight loss occurs and there is no rebound of weight 1-2 years later.
The main reason I’ve not jumped on the intermittent fasting band wagon is the shift in leptin, amylin, ghrelin and GLP-1 signaling that regularly occurs at the 6-12 month mark. The rebound of these hormones causes weight re-gain and is what prevents successful long-term weight loss. A number of people come to my office and tell me they couldn’t follow a ketogenic diet, so they’re doing intermittent fasting and it works . . . for a while. Then, they end up in my office having hit a plateau or fallen off the wagon and regained all the weight. They are completely confused and don’t understand what happned. Most of them are convinced it’s their thyroid or cortisol and they’ve seen every naturopath and functional medicine doctor in town.
What people really need is a simple approach to long-term weight loss without having to spend the night in the physiology lab every two weeks sleeping under a ventilated hood system.
The Ketogenic Lifestyle is a Pulsed Energy Lifestyle
Third, providing adequate fat is the simple way to maintain leptin, ghrelin, amylin, GLP-1 (among the others) and long-term weight loss. Can you eat too much fat? Of course you can. But, because each of us have differing levels of stress and activity each day, this fat intake becomes the lever for hunger control.
Fourth, the use of exogenous ketones ensures easily accessible ketone (short chain fatty acids) to modulate adipose (white fat) signaling of the liver without large caloric intake through the portal vein by first pass of liver metabolism. The ketones also help stabilize the gut bacteria. The combination of hormone balance between the liver and fat cells and improvement of gut bacteria suppresses key hunger hormones and aids glucose regulation between the fatty tissues and the liver. Ketones, both endogenous and exogenous, suppress production of TNF-alpha, IL-6, resistin, and stabilize production of adiponectin and leptin from the adipose cells (7, 8, 9).
In my office, once we calculate the basic protein needs daily, we start with a 1:1 ratio of protein to fat. Then, the fat is adjusted up or down based on hunger. Remember, hunger occurs, because your body produces hormones. The addition of fat to a diet that is not stimulating large amounts of insulin resets the hormone patterns back to normal without causing weight gain.
Give Obese People Fat Ad Libitum?
“Sure, Dr. Nally, but what about those people who don’t know if they are hungry, bored, stressed or just have a bacon fixation? You can’t just give them all the fat they want?!”
Why not? Implying that people aren’t smart enough to know when they are full is a bit of a fascist philosophy, don’t you think?
Do people over eat? Sure they do. But, I’ve found that when you give people an antidote to hunger (using fat intake in the presence of stabilized insulin levels) over a few months, people begin to recognize true hunger from other forms of cravings. This is especially true when they keep a diet journal. This gives people the ability to begin listening to their own bodies, responding accordingly and governing their stress, eating, exercise and activity. Keeping a diet journal is key to long-term weight loss. And, isn’t helping people use their own agency to improve their health really what we’re trying to do?
Interestingly, doing this over the years seems to line up with the findings of this year’s MATADOR study in the International Journal of Obesity. They found that mild intermittent energy restriction of about 30-33% for two weeks, then interrupting this with two weeks of a diet that was energy balanced for needs improved both short and long-term weight loss efficiency (4). In looking at my, and my patient’s diet journals, this energy restriction of about 1/3 of needed calories cyclically seems to happens naturally with a ketogenic lifestyle, without even counting calories. (Calories are a swear-word in my office).
What does the correct long-term wight loss program look like in a diet or meal plan? Well, you’ll have to join the Ketogenic Lifestyle 101 Course to see what that really means to you individually. I look forward to seeing you there.
Want to find out more about the Ketogenic Lifestyle 101 course? CLICK HERE.
Have you read my book The Keto Cure? Get a signed copy from me by clicking HERE.
References:
Bronson FH, Marsteller FA. “Effect of short-term food deprivation on reproduction in female mice.” Biol Reprod. Oct 1985; 33(3): 660-7. https://www.ncbi.nlm.nih.gov/pubmed/4052528?dopt=Abstract&holding=npg
Connors JM, DeVito WJ, Hedge GA. “Effects of food deprivation on the feedback regulation of the hypothalamic-pituitary-thyroid axis of the rat.” Endocrinology. Sep 1985. 117(3): 900-6. https://www.ncbi.nlm.nih.gov/pubmed/3926471?dopt=Abstract&holding=npg
Seimon RV, Roekenes JA, Zibellini J, Zhu B, Gibson AA, Hills AP, Wood RE, King NA, Byrne NM, Sainsbury A. “Do intermittent diets provide physiological beneftis over continuous diets for weight loss? A systematic review of clinical trials.” Mol Cell Endo. 15 Dec 2015. 418(2): 153-172. https://www.sciencedirect.com/science/article/pii/S0303720715300800
Byrne NM, Sainsbury A, King NA, Hills AP, Wood RE. “Intermittent energy restriction improves weight loss efficiency in obese men: the MATADOR study.” Int J Obes. 2018. 42:129-138. https://www.nature.com/articles/ijo2017206
Trepanowski JF, Kroeger CM, Barnosky A. “Effect of Alternate-Day Fasting on Weight Loss, Weight Maintenance, and Cardioprotection Among Metabolically Healthy Obese Adults.” JAMA Intern Med. Jul 2017. 177(7): 930-938. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2623528?redirect=true
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. “Long-term persistence of hormonal adaptations to weight loss.” N Engl J Med. 27 Oct 2011. 365: 1597-1604. http://www.nejm.org/doi/full/10.1056/NEJMoa1105816
Asrih M et al., “Ketogenic diet impairs FGF21 signaling and promotes differential inflammatory responses in the liver and white adipose tissue.” PlosOne. 14 May 2015. Open Access. https://doi.org/10.1371/journal.pone.0126364
Veniant MM et al. “FGF21 promotes metabolic homeostasis via white adipose and leptin in mice.” PlosOne. Jul 2012. Open access. https://doi.org/10.1371/journal.pone.0040164
Whittle AJ, “FGF21 conducts a metabolic orchestra and fat is a key player.” Endocrinology. 1 May2016. 157(5): 1722-1724.
I thought that over the next few weeks I’d address a number of Ketogenic Lifestyle Rules that I have adopted. These seem to help and bring a little clarity to one following a Ketogenic Lifestyle or someone on the road to becoming a true “Ketonian.”
The first of these rules is that there should ALWAYS be bacon in the fridge!
We address this rule and some interesting facts around having bacon in the fridge in this evening’s Persicope below. We also address the benefits of journaling, how to help stop binge eating, what are your real protein needs, and red-meat fear-mongering. We even discuss whether or not pigs like bacon. Enjoy!
(Just a note: I love Katch.me’s service; however, due to the contract language allowing Katch.me to have unlimited rights to my Periscope Videos, I have withdrawn from Katch and my videos are no longer available on this medium until the contract usage can be modified.)
Adrenal Fatigue? Adrenal Insufficiency? Cortisol? PseudoCushing’s Syndrome? What do these terms mean and why are they all over the internet these days? And, what do they have to do with your weight loss?
This was our topic this evening on PeriScope. Katch Dr. Nally speak about this topic with rolling comments at Katch.me/docmuscles. Or you can watch the video below:
If you’re not sure about what this is, you’re not alone. I think I’ve heard the term “Adrenal Fatigue” at lease four times a day for the last three months. If you ask your doctor, they’ll probably scratch their heads too. The funny thing is that “Adrenal Fatigue” isn’t a real diagnosis, but it is all over the internet and it shows up in the titles of magazines in the grocery store every day. There’s even and “Adrenal Fatigue For Dummies” so it must be real, right?!
No. It isn’t a real diagnosis. It is a conglomeration of symptoms including fatigue, difficulty getting out of bed in the morning, and “brain fog” that have been lumped together to sell an “adrenal supplement.” (Sorry, but that’s really what it is all about.) Do a Google search and the first five or six sites describing adrenal fatigue claim the solution is taking their “special adrenal supplement.”
I know what you’re thinking, “Your just a main stream, Western Medicine doctor, Dr. Nally, you wouldn’t understand.” Actually, I do understand.
Adrenal fatigue has risen in popularity as a “lay diagnosis” because many patients show up at their doctors office with significant symptoms that actually interfere with their ability to function, and after all the testing comes back negative for any significant illness, they are told that they are normal. But the patient still has the symptoms and no answer or treatment has been offered. It’s discouraging. . . very discouraging.
That’s because the symptoms are actually the body’s response to chronic long term stress. Many of my patients, myself included, have found themselves “stuck” in their weight loss progression, feeling fatigued, struggling to face the day, with a number of symptoms including cold intolerance, memory decline, difficulty concentrating, depression, anxiety, dry skin, hair loss, and even infertility in some cases. Is it poor functioning adrenal glands? No, your feeling this way because the adrenal glands are actually doing their job!!
If the adrenal glands weren’t working you’d experience darkening of the skin, weight loss, gastric distress, significant weakness, anorexia, low blood pressure, and low blood sugar. The symptoms are actually called Addison’s disease and it is actually fairly rare (1 in 100,000 chance to be exact). So what is causing the symptoms you ask?
There are a number of reasons, but one that I am seeing more and more frequently is “Pseudo-Cushings’s Syndrome.” Pseudo-Cushing’s Syndrome is a physiologic hypercortisolism (over production of cortisol) that can be caused by five common issues:
Chronic Physical Stress
Severe Bacterial or Fungal Infections that Go Untreated
Malnutrition or Intense Chronic Exercise
Psychological Stress – including untreated or under-treated depression, anxiety, post-traumatic stress, or dysthymia (chronic melancholy)
Alcoholism
The psychiatric literature suggest that up to 80% of people with depressive disorders have increased cortisol secretion (1,2,3). People with significant stressors in their life have been show to have an increased corsiol secretion. Chronic stress induces hyperactivity of the hypothalamic-pituitary-adrenal axis causing a daily, cyclic over production of cortisol and then normalization of cortisol after resolution of the stressor. This cortisol response is not high enough to lead to a true Cushing’s Syndrome, but has the effect of the symptoms listed above and begins with limiting ones ability to loose weight.
I’m convinced that this is becoming more and more prevalent due to the high paced, high-stress, always on, plugged in, 24 hour information overload lives we live.
What is cortisol? It is a steroid hormone made naturally in the body by the adrenal cortex (outer portion of the adrenal gland). Cortisol is normally stimulated by a number of daily activities including fasting, awakening from sleep, exercise, and normal stresses upon the body. Cortisol release into the blood stream is highest in the morning, helping to wake us up, and tapers into the afternoon. Cortisol plays a very important role in helping our bodies to regulate the correct type (carbohydrate, fat, or protein) and amount of fuel to meet the bodies physiologic demands that are placed upon it at a given time (4,5,6).
Under a stress response, cortisol turns on gluconeogensis in the liver (the conversion of amino acids or proteins into glucose) for fuel. Cortisol, also, shifts the storage of fats into the deeper abdominal tissues (by stimulating insulin production) and turns on the maturation process of adipocytes (it makes your fat cells age – nothing like having old fat cells, right?!) In the process, cortisol suppresses the immune system through an inhibitory effect designed to decrease inflammation during times of stress (7,8,9). If this was only occurring once in a while, this cascade of hormones acts as an important process. However, when cortisol production is chronically turned up, it leads to abnormal deposition of fat (weight gain), increased risk of infection, impotence, abnormal blood sugars, brain fog, head
aches, hypertension, depression, anxiety, hair loss, dry skin and ankle edema, to name a few.
The chronic elevation in cortisol directly stimulates increased insulin formation by increasing the production of glucose in the body, and cortisol actually blunts or block-aids the thyroid function axis. Both of these actions halt the ability to loose weight, and drive weight gain.
Cortisol also increases appetite (10). That’s why many people get significant food cravings when they are under stress (“stress eaters”). Cortisol also indirectly affects the other neuro-hormones of the brain including CRH (corticotrophin releasing hormone), leptin, and neuropeptide Y (NPY). High levels of NPY and CRH and reduced levels of leptin have also been shown to stimulate appetite and cause weight gain (10-11).
How do you test for Pseudo-Cushing’s Syndrome?
Testing can be done by your doctor with a simple morning blood test for cortisol. If your cortisol is found to be elevated, it needs to be repeated with an additional 24 hour urine cortisol measurement to confirm the diagnosis. If Cushing’s Syndrome is suspected, some additional blood testing and diagnostic imaging will be necessary. Pseudo-Cushing syndrome will demonstrate a slightly elevated morning cortisol that doesn’t meet the criteria for true Cushing’s type syndrome or disease.
How do you treat it?
First, the stressor must be identified and removed. Are you getting enough sleep? Is there an underlying infection? Is there untreated anxiety or depression present? Are you over-exercising? These things must be addressed.
Second, underlying depression or anxiety can be treated with counseling, a variety of weight neutral anti-depressant medications or a combination of both. Many of my patients find that meditation, prayer, and journaling are tremendous helps to overcoming much of the anxiety and depression they experience.
Third, adequate sleep is essential. Remove the television, computer, cell phone, iPad or other electronic distraction from the bedroom. Go to bed at the same time and get up at the same time each day. Give yourself time each day away from being plugged in, logged in or on-line.
Fourth, mild intensity (40% of your maximal exertion level) exercise 2-3 days a week was found to lower cortisol; however, moderate intensity (60% of your maximal exertion level) to high intensity (80% of your maximal exertion level) exercise was found to raise it (12). A simple 20 minute walk, 2-3 times per week is very effective. Find a hobby that you enjoy and participate in it once or twice a week. Preferably, a hobby that requires some physical activity. The activity will actually help the sleep wake cycles to improve.
Fifth, follow a low carbohydrate or ketogenic diet. Ketogenic diets decrease insulin and reverse the effect of long term cortisol production. Ketogenic diets a have also been shown to decrease or mitigate inflammation by reducing hyperinsulinemia commonly present in these patients (13).
So, the take home message is . . . take your adrenal glands off of overdrive.
References:
Pfohl B, Sherman B, Schlechte J, Winokur G. Differences in plasma ACTH and cortisol between depressed patients and normal controls. Biol Psychiatry 1985; 20:1055.
Pfohl B, Sherman B, Schlechte J, Stone R. Pituitary-adrenal axis rhythm disturbances in psychiatric depression. Arch Gen Psychiatry 1985; 42:897.
Gold PW, Loriaux DL, Roy A, et al. Responses to corticotropin-releasing hormone in the hypercortisolism of depression and Cushing’s disease. Pathophysiologic and diagnostic implications. N Engl J Med 1986; 314:1329.
Ely, D.L. Organization of cardiovascular and neurohumoral responses to stress: implications for health and disease. Annals of the New York Academy of Sciences (Reprinted from Stress) 771:594-608, 1995.
McEwen, B.S. The brain as a target of endocrine hormones. In Neuroendocrinology. Krieger and Hughs, Eds.: 33-42. Sinauer Association, Inc., Massachusetts, 1980.
Vicennati, V., L. Ceroni, L. Gagliardi, et al. Response of the hypothalamic- pituitary-adrenocortical axis to high-protein/fat and high carbohydrate meals in women with different obesity phenotypes. The Journal of Clinical Endocrinology and Metabolism 87(8) 3984-3988, 2002.
Wallerius, S., R. Rosmond, T. Ljung, et al. Rise in morning saliva cortisol is associated with abdominal obesity in men: a preliminary report. Journal of Endocrinology Investigation 26: 616-619, 2003.
Epel, E.S., B. McEwen, T. Seeman, et al. Stress and body shape: stress-induced cortisol secretion is consistently greater among women with central fat.
Psychosomatic Medicine 62:623-632, 2000.
Tomlinson, J.W. & P.M. Stewart. The functional consequences of 11_- hydroxysteroid dehydrogenase expression in adipose tissue. Hormone and Metabolism Research 34: 746-751, 2002.
Epel, E., R. Lapidus, B. McEwen, et al. Stress may add bite to appetite in women: a laboratory study of stress-induced cortisol and eating behavior.Psychoneuroendocrinology 26: 37-49, 2001.
Cavagnini, F., M. Croci, P. Putignano, et al. Glucocorticoids and neuroendocrine function. International Journal of Obesity 24: S77-S79, 2000.
Hill EE, Zack E, Battaglini C, Viru M, Vuru A, Hackney AC. Exercise and circulating cortisol levels: the intensity threshold effect. J Endocrinol Invest. 2008. Jul;31(7):587-91.
Fishel MA et al., Hyperinsulinemia Provokes Synchronous Increases in Central Inflammation and β-Amyloid in Normal Adults. Arch Neurol. 2005;62(10):1539-1544. doi:10.1001/archneur.62.10.noc50112.
Join me as we chew the phat of ketogenic lifestyles PeriScope style and answer many questions like, “Why do I get ‘hangry’?” What causes hypoglycemia? How many times a day should I eat? and many more . . .
We talk briefly about why 60% of people with insulin resistance may need methylated folic acid to help with B vitamin absorption/use and where it can be found. (See me recent article about this called The Power of a Good Vitamin.)
You can see the whole PeriScope conversation on Katch.me/docmuscles with the comments scrolling or you can see the video stream below:
There are three constants in life: change, choice & principles. Change, ironically acting as a constant, is the variable that we have limited control over. Accepting that change is going to happen, that change is constant, and making choices to prepare for those changes is the key to success. My last post introduced the 10 Principles of the Ketogenic Lifestyle. This post will discuss choice as a foundation for those principles outlined in the ketogenic lifestyle. Choices are directly influenced by the balance between the mind, the body and the spirit of man.
LIFESTYLE PRINCIPLE 1 – WHEREVER YOU GO, THERE YOU ARE
People seem to get sidetracked off a ketogenic lifestyle for a number of reasons, but the most common I hear is that they were traveling, had company visit or they were on vacation. Successfully living a lifestyle requires that you first know who you are and where you are before you can consistently make good, solid, principle based choices. So I ask, who are you? Are you defined by your job, by your finances, by your travels, by your friends or by your vacations? Each of these experiences is unique. Our experiences place both good and bad before us. I have come to learn over time and countless interactions with people that nothing is coincidental. Everything, good and bad, happen for a reason.
Today’s society teaches the Pleasure Principle. This is the human instinct to seek pleasure and avoid pain, including avoiding painful recollections. We often define ourselves by those things that bring us pleasure. We each go through personal tests, failures and triumphs. Some of us harness all of those experiences for good, others find worsening mental paralysis due to fear of them. We often hide from the painful experiences and attempt to bury or forget them. Food is often involved with many of the experiences of life, and for a significant number of people, the endorphin release from eating a meal, sometimes just the act of chewing, may be the only pleasure one experience in a day, in a week or a in a year. Many people hide from painful recollections behind the simple pleasure produced by the eating of “comfort foods.” Food, and our opportunities to experience pleasure from it’s various flavors, textures and physical stimulus, begin to define us. However, hiding from life’s painful memories with momentary pleasures usually prolongs or makes the problem worse. The ingestion of simple foods containing glucose and fructose, their effect on the liver, and the hedonistic hormonal response is the basis of addiction, and simple carbohydrates provide the perfect fix.
Fascinatingly, when fructose is metabolized in the liver, in the presence of glucose (the basic structure of sugar – one fructose molecule bound to a glucose molecule), the byproduct has a hedonic (pleasure experiencing) effect on the exact same pleasure receptors in the brain that bind to morphine. Yes, that’s why the M&M’s make you forget your troubles and why the Jolly Rancher is so jolly. And, its the same reason you crave another do-nut two hours after you ate the entire baker’s dozen.
Although obesity has been recognized as a disease, our use of foods to celebrate with people or events in life is still a form of pleasure seeking. Excuses to deviate from healthy behavior under the guise of family, vacation, or social requirements, acknowledges our willingness to hide from pain with hedonic drugs like chocolate chip cookies and cotton candy. In fact, it’s usually a welcomed and and expected acceptable excuse.
“Dr. Nally, I can cheat eat and bad, (meals loaded with starch) because I’m on vacation” . . . from my problems. It’s so acceptable, we’ve based movie themes around it.
Healing can only occur when one is willing to confront and talk about the reasons, the real reasons you’d rather experience the endorphins from the do-nuts with your family instead of acknowledge your weakness, stresses, and fears. Many of us are so afraid of where we might be, we avoid acknowledging where and who we are. It takes courage not to take the easy path. And I will be the first to admit, pizza is the easy path and it’s scenic views are decorated with french fry palms and sunset clouds of apple fritters.
“There appears to be a conscience in mankind which severely punishes the man who does not somehow and at some time, at whatever cost to his pride, cease to defend and assert himself, and instead confess himself fallible and human. Until he can do this, an impenetrable wall shuts him out from the living experience of feeling himself a man among men. Here we find a key to the great significance of true, un-stereotyped confession – a significance known in all the initiation and mystery cults of the ancient world, as is shown by a saying from the Greek mysteries: “Give up what thou hast, and thou will receive.” (Carl Jung)
We have a choice about what to eat and when to eat, however, each choice has a reward and/or a consequence.
Points of Focus: Where are you and what are you hiding from? Sharing your weaknesses actually empowers you you overcome them. This can often be accomplished through the simple act of journaling, planing your meals the day before and journaling your successes and failures in that plan the following day. Allowing yourself and others insight into your times of weakness actually brings strength. It allows one to look at the reasons for food choices base on how you feel, and how you felt after the choice. If forces one to think about a choice before it ever has to be made. In my 15 years of medical practice, I have yet to hear a child find fault with a parent who worked tirelessly to make ends meet, admittedly struggled with alcoholism, battled against disease or fought against belittling for a belief. The child has always expressed their admiration of their parent’s courage and understanding of why decisions were made, even when erroneous. It takes courage to admit that wherever you go – there you are.
LIFESTYLE PRINCIPLE 2 – KEEP IT REAL
I no longer believe in coincidence. Whether you have thought about it or not, every interaction you have with others (even our interaction . . . your reading this blog), are not by coincidence. There is a reason. Whether you believe it or not, everything around us testifies that God exists; the Hand of Providence can be seen from the rotation of the earth, planets and stars, the precision of the seasons, the balance of the atmosphere allowing for the perfect pressures and concentration of elements to sustain a life giving breath, to the perfect replication of DNA within billions of cells throughout the body. I’m not trying to get religious, and, no, I can’t prove this through the scientific method . . . But, if the Big Bang started the universe, what started the Big Bang? Where did the first atom or molecule or particle of dust come from? I have a very difficult time accepting that you and I are here by accident, by a chaotic explosion that created order. That implies that there must be a plan, and that plan had to have been set in motion by a Creator. That also implies that that Creator placed solutions to our challenges, including the diseases of civilization, within our grasp and available to those seeking the solutions upon the earth today.
I have seen enough in my medical career to know that simple coincidence has frequently become significantly important, life changing and often life saving. This does not happen by accident and screams loud and clear that there is a plan for you and me. No good father would lock his child in a room without doors or windows or any escape without everything in the room, both good and bad, pointing to the reason the child was in the room, and pointing the way for the child to become his or her best self, physically and emotionally. Life has meaning. It is supposed to. If we get off track, coincidence and interactions lead us back.
“Behold, the hour cometh, yea, is now come, that ye shall be scattered, every man to his own, and shall leave me alone: and yet I am not alone because the Father is with me.” (John 16:32)
The Bible, among other records, records the voices of men and women from years past transcribing their experiences with the Hand of Providence, how that spiritual void was filled, how it helped the with choice and how our lives have deeper meaning and consequence, even amidst significant adversity.
Take a week and look at the synchronicity of your life. Journal about it. Don’t dismiss a second invitation from someone to discuss an opportunity or meet someone your friend thinks could be important to you, open that book that someone left behind on the subway seat beside you. Don’t assume it is meaningless, that some kind person returned your sunglasses or your wallet. Look at the simple interactions and recent relationships. These are the breadcrumbs and the street signs from a loving Creator, a loving Father.
Keeping it real means nothing less than complete authenticity. The last place you want to be is in the first-class seat on the plane to no-where. Have the faith to get off the plane and take the bus, ride your bike, or even swim upstream in the direction you’re supposed to be going. Look for the coincidences, bread crumbs and spiritual street signs in your life.
How does this relate to a ketogenic lifestyle? Every religion or spiritual tradition speaks of a polestar. The polestar is that anchor to which the entire solar system is tied by invisible aerial chords and the engine that powers the universe. Those cords are connected with our own individual polestars. A ketogenic lifestyle is one that encompasses mind, body and spirit. It is a lifestyle that demands that you link and align your personal polestar with the truth inside and around you. It takes both courage and faith, but it brings immeasurable strength and help in achieving your goals. A person out of balance with life is under stress. Chronic stress produces excessive cortisol and other powerful adrenal hormones that displace the body’s and the mind’s endocrinologic balance, leading to weight gain, weight retention, and chronic disease. This often has significant effect externally on the body in processes seen like depression, anxiety, fibromyalgia, and allowing for amplification of inflammation and auto-immune dysfunction. We refer to this inter-relationship in the medical community as psychosomatic and/or viscerosomatic dysfunction, the psyche (the mind) and/or the viscera (internal endocrine organs) directly and adversely influence the function of the soma (the structural body separate from the mind).
“He who does not know himself, does not know anything, but he who knows himself, knows the depth of all things.
” . . . If you bring forth what is within you, what you bring forth will save you. If you do not bring forth what is within you, what you do not bring forth will destroy you.” (Book of Thomas the Contender)
Point of Focus: Your life is never without meaning. Keep it real by recognizing that diet alone may not compete your answer for physical health. Having courage and faith allow you to see and embrace the truth that is right in front of you. The Alcoholics Anonymous’ 12 step program only becomes successful when one realistically and courageously applies their faith to align with the truth they have felt all along. For any long-term lifestyle change to take place, one must connect and live the principles before one truly knows they are true. In this way the Ketogenic Lifestyle becomes real.
KetoOS – Drinkable Exogenous Ketones
LIFESTYLE PRINCIPLE 3 – TO cheat, or NOT to cheat, that is the question
I have been asked this question by every patient I have placed on a ketogenic diet at least once and often three or four times throughout the course of our treatment plan. I usually answer this question with a question. “Why do you want to cheat?”
The desire to cheat usually arises form one of three reasons:
You’re not eating enough fat to satiate your appetite and you are truly hungry. The body recognizes that it can use and absorb glucose much faster than fat, as fuel, so it naturally will crave “sweets.” In this case, the case of true hunger, solution is to increase your fat intake. You should be eating at least 50% of your total calories in the form of fat.
Insulin loads are still high, stimulating rebound hunger and hedonistic cravings. You’re either eating too many carbohydrates with your diet or you’re using a sweetener that stimulates insulin without raising blood sugar (See my article The Skinny about Sweeteners).
Cheating with a specific food fulfills a psychological need, feeds an addiction or represents an obligation to fulfill a societal ritual. Journaling helps to identify and break this cycle.
If you are truly in ketosis the cravings to cheat don’t exist, they actually disappear. Other societal rituals, like birthdays, anniversaries, weddings, spiritual ceremonies or rites of passage are often tied to or use food as symbolism. In these cases, the decision to cheat is really yours.
When a person cheats, it can take as many as 3-5 days to get back into ketosis, and for some 2-3 weeks. Carbohydrate cravings will rebound and often be present for up to 72 hours after cheating. You have to decide if cheating is worth 3 days of carbohydrate cravings and 3-7 days of stifled weight loss.
Point of Focus: There are no Ketosis Police! Really. They don’t exist! Dr. Nally will not show up in uniform on your doorstep with a set of handcuffs and a bag of pork rinds. You won’t be arrested for eating bread and those of us who have been following a strict ketogenic lifestyle for years really don don’t mind at all if you decide to cheat. We will smile and we may even ask you how it tastes or if you liked the flavor, but don’t be self-conscious, because when one is in ketosis for a few months, we really don’t crave cheating any longer, and we won’t judge you. And, don’t feel obligated to justify why your cheating, this is a lifestyle. You probably won’t ask me why I chose to wear long sleeves on a hot day in Arizona, for the same reason I won’t ask you why you decided to wear a Speedo.
LIFESTYLE PRINCIPLE 4 – Hunger Management
Life comes at you pretty fast and if you’re not prepared, hunger can bite you. Most people fall off the wagon when they are unprepared for missing a meal on a stressful day. I’ve recently heard the argument that “there is no wagon, so don’t worry about falling off.” This is false security that leaves one unprepared for life events. Pioneers traveled in wagons for two reasons. First, the wagon held supplies essential for survival. Second, wagons usually traveled in wagon trains. This means that there was more than one person on the wagon and there was more than one wagon on the trail with you. Traveling with a wagon train meant you had others on the same trail with the same tools for safety and support.
In the world of fast foot, fast photos and speedy delivery, we often don’t adequately prepare for hunger or cravings. There are some essential hunger management tools for the Ketogenic Lifestyle:
Eat meals containing >50% fat. This, in and of itself, delays hunger and ensures the satiety center of the brain is happy for longer periods of time.
Carry rescue foods with you or keep them at your office or in your fridge at home. These include low-carb nuts like almonds, walnuts, macadamia nuts; Keep hard and string cheese handy for a snack. Use sliced deli-meats with the cheese as a snack when the cravings kick in. Pork Rinds, beef jerky, olives, are great natural food options.
If you have time and can cook, develop your favorite “Fat Bombs“ and have a bag full in the fridge for those cravings.
Having the moral support of a buddy, spouse, friend or work companion who checks on your progress daily, assists with meals and meal choices is priceless. Periscope, a free Twitter based App, has become a means of checking in with your Ketogenic Support group around the world that connects to those you follow on Twitter. You can follow me, @docmuscles, and a number of fascinating health Periscopes that focus on ketogenic, low-carb, whole food paleo approaches: @livinlowcarbman, @_danielleeaton, @kasandrinos, @fatissmartfuel, @domskitchen, @mikemutzel, @keribrewster, @tombilyeu, @glutenfreenj, @paleocomfort.
Being accountable to yourself in a diet journal daily and to your doctor regularly every 1-2 months also helps keep motivation going forward. Jimmy Moore, author and podcaster at the Livin’ La Vida Low-Carb Show has also posted one of the most extensive lists of physicians specializing in ketogenic diets from around the world. You can find that list here.
LIFESTYLE PRINCIPLE 5 – Stress Reduction
Pages and pages can be written about stress reduction. In fact, I’ve written about the chemical responses that stress has on weight gain in my post, Stress. . . The Weight Loss Killer. But there are a few daily essentials that should be added into the Ketogenic Lifestyle to manage stress.
First, are you getting adequate sleep? Remove the television, computer, cell phone, iPad or other electronic distraction from the bedroom. Go to bed at the same time and get up at the same time each day. Give yourself time each day away from being plugged in, logged in or on-line.
Second, over exercising or being malnourished can cause chronic stress. I have a number of patient that have been convinced that they have to work out 60 minutes a day 6-7 days per week. It is essential that you realize muscles need a minimum of 48-72 hours to recover from specific types of exercise. If you run for 60 minutes. It will take your muscles 48 hours to recover from the running. If you do upper body weight lifting, it will take 48-72 hours for those muscles to recover from that weight lifting. Exercising the same muscle group with the same exercise over stresses the muscles and leads to significant chronic stress, spiking the cortisol levels and halting weight loss and raising cholesterol & triglycerides. Under eating or fasting to starvation has the same effect.
Third, mild intensity (40% of your maximal exertion level) exercise 2-3 days a week was found in a recent study to lower cortisol and decrease over-all stress, raising serotonin and dopamine in the brain; however, moderate intensity (60% of your maximal exertion level) to high intensity (80% of your maximal exertion level) exercise was found to raise it. A simple 20 minute walk, 2-3 times per week is very effective at stress reduction, reduction in cortisol and improvement in ketosis.
Point of Focus: The goal is cortisol reduction. This can be done through regular and restful sleep and mild exercise. Chronic elevation in cortisol directly stimulates an increase in insulin by increasing the production of glucose in the body, and cortisol blockaids the thyroid axis. Both of these actions halt the ability to loose weight, amplifies the production of inflammatory hormones and drives weight gain. Cortisol also increases appetite. That’s why many people get significant food cravings when they are under stress (“stress eaters”). Cortisol also indirectly affects the other neuro-hormones of the brain including CRH (corticotrophin releasing hormone), leptin, and neuropeptide Y (NPY). High levels of NPY and CRH and reduced levels of leptin have also been shown to stimulate appetite.
Hopefully, this gives you some starting points and direction to your Ketogenic Lifestyle. If I’ve missed something that you’ve found to be essential, let me know. Its always great to hear what has helped you in your Ketogenic journey. Until next time, pass the butter!!!
So, how do you manipulate the hormones in a way to control the rebounding hunger and suppression of metabolism? This is where we put a bit of twist on the knowledge we’ve gained from alternate day fasting. Recent research shows that “mild” energy deficit in a pulsatile manner, that has the ability to mimicking the body’s normal bio-rhythm’s is dramatically effective in reducing weight and maintaining normal hormonal function without cause of rebound metabolic slowing (4).
People with significant stressors in their life have been show to have an increased corsiol secretion. Chronic stress induces hyperactivity of the hypothalamic-pituitary-adrenal axis causing a daily, cyclic over production of cortisol and then normalization of cortisol after resolution of the stressor. This cortisol response is not high enough to lead to a true 
Under a stress response, cortisol turns on gluconeogensis in the liver (the conversion of amino acids or proteins into glucose) for fuel. Cortisol, also, shifts the storage of fats into the deeper abdominal tissues (by stimulating insulin production) and turns on the maturation process of adipocytes (it makes your fat cells age – nothing like having old fat cells, right?!) In the process, cortisol suppresses the immune system through an inhibitory effect designed to decrease inflammation during times of stress (7,8,9). If this was only occurring once in a while, this cascade of hormones acts as an important process. However, when cortisol production is chronically turned up, it leads to abnormal deposition of fat (weight gain), increased risk of infection, impotence, abnormal blood sugars, brain fog, head
