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The Shovel will Fail You in Obesity, Finances & Life

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.

  1. Pick one small debt and begin to pick at it by applying just a little extra each month until it is gone.
  2. Cancel your extra cable, sell the motorcycle and payoff the 21% interest credit card.
  3. 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.

  1. Kiss your wife every time you leave, even if it’s just for a ten minutes to run to the convenience store.
  2. Hold her for five seconds longer every time you hug.
  3. Find a gift you can give her once a week, just because.
  4. 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.
  5. 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.

  1. Start with one meal and make some substitutions.  My dietary plan can help you with this.
  2. 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.
  3. Add a quality vitamin to your morning routine.
  4. Take ten minutes and do 20 push-ups and 20 sit-ups, then take a 10-minute walk.
  5. Simply remove the “white stuff” from your meals. You will be amazed at the results.
  6. 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.

If you’re looking for a program that teaches you how to do this, check out my membership site.

8 Reasons You Can't Lose Fat #DocMuscles #KetonianKing DocMuscles.com

Eight Reasons You Can’t Lose Fat

Inability to lose weight is the most common reason people see me. It’s often a combination of small things of which they are unaware.  What simple things are keeping the spare tire inflated around the your waist?  I’ve listed the eight most common reasons you can’t lose the fat.

You Eat Too Many Carbohydrates

About 85% of the people that walk through my office doors have some degree of insulin resistance. This means that they produce 2-20 times the normal amount of insulin in response to ANY form of starch or carbohydrate. Insulin is the hormone responsible for letting glucose into the cell to be used as fuel. More importantly, it is the hormone responsible for dampering glucose production in the liver and, it is the primary hormone responsible for pushing triglycerides into the fat cells (essentially, the master hormone for making you FAT). The more insulin you make the more fat you store. Insulin resistance, the inability for insulin to signal glucose dampering at the liver receptors, is the first stage that starts 15-20 years before you become a diabetic.

#DocMuscles #KetonianKing #WeaponOfMassDestructionIn order to lose fat, you have to decrease the insulin to a basal level. If you don’t the fat enters the fat cell faster than it exits and the fat cells get bigger. This is RULE number one to weight loss. You gotta turn down the high insulin surge that 85% of us are really good at producing. If you don’t do this, it is almost impossible for many of us to lose weight.

For at least 1/3rd of the people I see, this cannot be accomplished unless TOTAL CARBOHYDRATES are decreased to less than 20 grams per day. Yes, you read that correctly . . . Less that 20 grams per day.

  • Your banana contains 30 grams of carbohydrate
  • Your yogurt has up to 60 grams of carbohydrate
  • That oatmeal you thought was good for you has up to 200 grams of carbohydrate
  • The half and half you put in your coffee is half lactose (sugar from milk), 10 grams per cup.

You Eat Too Much Protein

Yes, protein can cause weight gain.  And, no, it’s not because gluconeogenesis is on overdrive.  There is always a body builder that sends me a nasty message after I say this.  But the fact is that it’s true. (I’ll keep an eye on my e-mail).

#EatMoreChicken #DocMuscles #KetonianKing #TooMuchProtein

Five of the ten essential amino acids stimulate an insulin response. Remember why carbohydrates cause weight gain . . . ? (I will give you a hint . . . INSULIN).

Certain amino acids that make up proteins can do the same thing.  Arginine, Lycine, Phenylalanine, Leucine & Tyrosine, in that order, stimulate insulin enough to halt weight loss or increase weight gain in a significant way (1).  We need protein to stay healthy, but too much of these amino acids in someone who is insulin resistant will inhibit weight loss and stimulate fat gain.  I’ve also seen it raise small dense LDL particles in the cholesterol (the heart disease causing particle driven by insulin over production)  I’ve seen this time and time again with many people.  Simply modulating down the protein to the calculated needs lets the weight start coming off again.

So, what foods contain these in the highest amounts? Sea lion liver (I know, this won’t go over very well with the polar bears), soy protein isolate, crab, shrimp, sesame flour, turkey breast, pork loin (it’s the leanest cut of pork – No. BACON is fine), chicken, pumpkin seeds, soybeans, peanuts, spirulina (blue green alge that is found in the sea).

Yes, I get it. We’ve been told these were the healthy foods for the last 50 years. But, think about it. When did we start gaining weight as a country? 50 years ago.

Too much chicken, shrimp, crab and soy foods will inhibit weight loss in those with insulin resistance. So, consider whether it should be chicken you add to your salad. Consider, instead, bacon or beef as a wonderfully tasty substitute.

How much protein do you need?  My formula for calculating your individual amount is here in my blog Calculating Protein Needs.

You Don’t Eat Enough Fat

#Snaccident #DocMuscles #KetonianKing #BaconBoy

To successfully lose fat on a ketogenic diet, 30-70% of your caloric intake should come from fat. Yes. You read that correctly. (The definition of a high fat diet is any diet containing more than 30% of fat from calories).

If we limit carbohydrates (which is currently 80% of the body’s fuel on the standard America plate), and moderate excessive protein which also halts weight loss, you have to replace the fuel. That fuel replacement should come from fat.  Increasing fat will improve the sensation of fullness, provide all the fat soluble vitamins, and actually makes food taste good again.

As long as you are lowering the insulin to basal levels, you can actually eat all the fat for which you are hungry. Add bacon, butter, coconut oil, avocado, hard cheese, and oh, did I say bacon?

But Dr. Nally, what about all that saturated fat?

The saturated fat is only a problem with vascular disease, cholesterol and heart disease when the insulin level is also high at the same time. It’s the high insulin in the presence of large amounts of fat that drives the risk for atherosclerosis (vascular and heart disease).  Instead of cutting out the fat, we’re cutting out the insulin.

How much fat should you be eating? Shoot for 60-70% of your calories from fat for the first 3 months.  If your fat grams are slightly higher than or equal to your protein grams, you’re there. Listen to your body and eat fat until you’re full. That’s how most of my patients gauge their need and suppress hunger.

You’re Now Eating Too Much Fat

After the third month, most of us are fat adapted.  You may notice your weight loss slows or halts. This means that our ability to absorb fat into the blood stream is dramatically more efficient.  It also means that your taking in more fat into the fat cell then you are pulling out of the fat cell.  I’ve found this to be the case with people who are loading butter, MCT or heavy whipping cream into their coffee.  In this case, back off the “extra fat” your are loading or drinking.  It’s not the calories  in this case.  There are 3-4 hormonal reasons this occurs once you are fat adapted.  (We’ll talk about this in another blog post.)

You’re Drinking Tea

Black Tea #KetonianKing #DocMuslces #WeightLoss #KetosisI know, I know.  Tea is a national pass time in Europe. And, it is deeply embedded in the culture of many other countries.  I’m probably not winning any friends across the pond by saying this, and it may bring back memories of the Boston Tea Party.  However, the problem is that leaf based teas stimulate a rise in insulin (not taxes).  I have had many patients hit a weight loss plateau because of the use of tea, specifically black tea, oolong tea, and green tea (2,3,4).

Yes, I am well aware of the tremendous benefits of the epigallocatechin gallate (ECGC) found in green tea. ECGC, which can be isolated as an extract, improves insulin resistance and improves GLP-1 signaling.  ECGC has, also, been show to improve triglycerides (5).  For this reason, it is one of the components in the KetoEssentials Multi-Vitamin I developed a few years ago and recommend to all my patients.

It appears, however, that the theaflavin within the leaf of the tea may be playing the offending role in the insulin spike seen with their use (6).

You Don’t Get Enough Sleep

Lack of sleep has been implicated in difficulty with weight loss and weight gain (7). Lack of sleep places the body into a state of chronic stress. This elevates cortisol, lowers testosterone, increases insulin (there’s that insulin problem, again) and increases the other inflammatory hormones. This perfect storm of stress, driven by lack of restful sleep, plays a big role in fat loss.

My average patient needs at a minimum of 6-7 hours of restful sleep to maintain and lose weight.

This is where untreated sleep disorders like sleep apnea play a big role. If you have sleep apnea, get it treated. What else can you do to help improve sleep?

  • Remove the computer, iPad and cell phones from the room.
  • Lower the room temperature. Men sleep better around 68-70 degrees F and women sleep better when the temperature is <70 degrees F.
  • Close the blinds or shades to add or darken the room.
  • Don’t study or watch TV in the same room you sleep in. Your body gets used to doing certain activities in certain rooms of the house. The bedroom should be reserved for sleep.
  • Go to bed at the same time
  • Get up at the same time.

It may take your body and body’s biorhythm 3-4 weeks to adjust to changes you make around sleep habits. Be patient with yourself.

You’re Married to Stress

Just as lack of sleep is stressful, other forms of chronic stress also raise cortisol, insulin and the inflammatory hormones. Chronic stress also lowers testosterone. It, also, has the potential to lower neurosignaling hormones in the brain like serotonin and dopamine, putting you at greater risk for depression and anxiety.

Other forms of chronic stress can occur from poor relationships, chronic pain, stressful employment, unfulfilled expectations, chronic illness and all forms of abuse. If any of these are playing a role in your life, you need to address them, and address them now.

As a physician, my job is stressful. Dealing with life and death issues with multiple people through the day, six or seven days a week, takes it’s toll. I’ve found that weight lifting, horseback riding, and taking care of my animals are my outlets. Find something physical, that takes you outside in the elements and forces you to break a sweat for 15-20 minutes is the key.

#FightOrFlight #DocMuscles #KetonianKing Bear Chasing ManOur bodies have a “fight or flight system.” 100 years ago, the stress was fighting or running from the bear that squared off with you when you happened upon him in the woods. Cortisol, adrenaline, epinephrine, insulin, glucose, and inflammatory hormones pour into the blood stream.  The heart beats faster, blood flows rapidly to the muscles, sensory awareness is heightened in the brain and increased oxygen flows to the lungs. This lets you fight the bear or run from the bear.

But, you can’t fight or run from your cynical boss. You can’t fight or run from oppressive finances, the person that cuts you off on your one hour commute in traffic, or your coworker who keeps pestering you. However, your body still releases adrenaline, cortisol, epinephrine, insulin and a number of inflammatory hormones prepping you to fight or run. If you don’t burn these hormones off, they halt weight loss, and actually can cause weight gain, increase anxiety and over time disrupt sleep.

So find your favorite way of physically relieving stress, and do it 2-3 times per week. (No, gentlemen, sex doesn’t count).

You Have An MTHFR Deficiency

In the last few years, we’ve been able to identify a number of genetic deficiencies that play a role in weight gain. One of those is an methyl-tetrahydrofolate enzyme deficiency (MTHFR deficiency for short). This is a genetic deficiency in the enzyme that converts adds a methyl ion to the folic acid in the cells of your body.

This is important, because if you can’t methylate folic acid inside the cell, you’ll have difficulty using vitamin B12 and B6 very efficiently to form methionine (a key amino acid in blood vessel and nerve function). There are two genes that encode for the enzyme that does the methylation of folic acid. Deficiency in one or both of these can lead to problems.

In severe cases, it causes homocysteine to build up to unsafe levels in the blood and slow the formation of methionine.  It is associated with B12 deficiency, weight gain, fatigue, migraines, depression, anxiety, neuro-developmental disorders like autism, pregnancy loss, blood clots and neuropathy in pre-diabetic and diabetic patients (8, 9, 10).

Giving extra vitamin B12, B6 and folic acid (vitamin B9) doesn’t appear to help.  Clinical evidence is pointing to the pre-methylated form of the folic acid.  Finding this pre-methylated form has been difficult and notably expensive for patients. I found this deficiency to be so prevalent in my office, I added methylated folic acid to the KetoEssentials Multivitamin.

You Give “Couch Potato” A New Name

We have become a very sedentary people. We have engineered physical activity out of our lives. Remote controls, elevators, escalators, people movers, and automation have made our lives physically easier.

The average office worker burns 300 kcal per day sitting at a desk on a computer. The average farm worker burns 2600 kcal per day. That’s the equivalent of running a marathon every day.

Physical activity doesn’t necessarily cause weight loss.  However, physical activity changes the hormones of the body including increasing a hormones like catacholamines, testosterone and a hormone called atrial naturitic peptide (ANP).  ANP opens the fat cell, and lets more fat out (11).

When physical activity is paired with the correct diet, the weight come off.  This is where exogenous ketones may play a role.  The increased presence of ketones in the blood increases the release of ANP helping to activate triglyceride release from the fat cell.

Don’t get me wrong, many of my patients can lose weight with just dietary carbohydrate restriction alone, however, if you’ve hit a stall, you may need to look at your physical activity levels and many people like me, who are notably insulin resistant, benefit greatly with the addition of exogenous ketones.

Kickstart Ketosis over the Plateau

Is your fat loss on a plateau?  Knowing that these challenges plague people on and off throughout the year, and, seeing people get hung up on these issues, I’ve created the Ketogenic Lifestyle 101 Course.  This program gets you jump-started into ketosis and gives you the tools to overcome the individual hurtles you will experience on your health journey.

If your the really motivated type, and want a true 30 day challenge, then join my Kickstart program.

References:

  1. Floyd J et al., Stimulation of Insulin Secretion by Amino Acids, Journal of Clinical Investigation. 1966. 45(9).
  2. Bryans JA et al., Effect of black tea on post-prandial glucose and insulin. Journal Am Coll Nutrition 2007, 25(5): 471-7.
  3. Store KS & Baer DJ. Tea consumption may improve biomarkers of insulin sensitivity and risk factors for diabetes. The Journal of Nutrition. Aug 2008, 138(8): 1584S-1588S.
  4. Hosoda K et al., Anti-hyperglycemic effect of oolong tea on type II diabetes. Diabetes Care. Jun 2003. 26(6): 1714-1718.
  5. Chia-Yu Liu,Chien-Jung Huang, Lin-Huang Huang, I-Ju Chen, Jung-Peng Chiu, Chung-Hua Hsu.  Effects of Green Tea Extract on Insulin Resistance and Glucagon-Like Peptide 1 in Patients with Type 2 Diabetes and Lipid Abnormalities: A Randomized, Double-Blinded, and Placebo-Controlled Trial. PLOS one(online). March 10, 2014.
  6. Cameron, Amy R.; Anton, Siobhan; Melville, Laura; Houston, Nicola P.; Dayal, Saurabh; McDougall, Gordon J.; Stewart, Derek; Rena, Graham (2008). “Black tea polyphenols mimic insulin/insulin-like growth factor-1 signalling to the longevity factor FOXO1a”. Aging Cell. 7(1): 69–77.
  7. Beccuti, Guglielmo, and Silvana Pannain. “Sleep and Obesity.” Current opinion in clinical nutrition and metabolic care 14.4 (2011): 402–412. PMC. Web. 18 Sept. 2017.
  8. Divyakolu S, Tejaswini Y, Thomas W, Thumoju S, et al. (2013) Evaluation of C677T Polymorphism of the Methylenetetrahydrofolate Reductase (MTHFR) Gene in various Neurological Disorders. J Neurol Disord 2:142. doi: 10.4172/2329-6895.1000142
  9. Gilbody, S., Lewis, S. & Lightfoot, T. (2007). Methylenetetrahydrofolate reductase (MTHFR) genetic polymorphisms and psychiatric disorders: A HuGE review. American Journal of Epidemiology, 165(1), 1-13.
  10. Menon, S., Lea, R., Roy, B., Hanna, M., Wee, S., Haupt, L., & … Griffiths, L. (2012). Genotypes of the MTHFR C677T and MTRR A66G genes act independently to reduce migraine disability in response to vitamin supplementation. Pharmacogenetics And Genomics, 22(10), 741-749.
  11. Lafontan M et al., Control of lipolysis by natriuretic peptides and cyclic GMP. Trends in Endocrinology and Metabolism. 19(4): 130-137.

Why Be In Ketosis – Part X: PPAR-alpha

Benefit #10 in my 25 part series on “Why Be In Ketosis?”

This evening we briefly discuss PPAR-α, a powerful hormone that is stimulated by the ketogenic state.  It has a number of known benefits.  A number of great questions also popped up that we answered.  Listen and watch as we discuss them here:

Stay tuned for more great content on Facebook Live, Periscope and Instagram.

Too Much Fat on a Ketogenic Diet?

bacon eggsIf you are interested in the low-carb, moderate protein, high-fat, ketogenic diet, then this is the podcast for you. We zero in exclusively on all the questions people have about how being in a state of nutritional ketosis and the effects it has on your health. There are a lot of myths about keto floating around out there and our two amazing cohosts are shooting them down one at a time. Keto Talk is cohosted by 10-year veteran health podcaster and international bestselling author Jimmy Moore from “Livin’ La Vida Low-Carb” and Arizona physican and certified bariatric physician Dr. Adam Nally from “Doc Muscles” who thoroughly share from their wealth of experience on the ketogenic lifestyle each and every Thursday. We love hearing from our fabulous Ketonian listeners with new questions–send an email to Jimmy at livinlowcarbman@charter.net. And if you’re not already subscribed to the podcast on iTunes and listened to the past episodes, then you can do that and leave a review HERE. Listen in today as Jimmy and Adam answer more engaging questions about nutritional ketosis from you the listeners today in Episode 17!

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KetoOS
KetoOS – Drinkable Exogenous Ketones

Healthy Ketogenic Bio-Hacking…Come Learn How

Biohacking

Ever wondered if it is possible to change up your metabolic genetics for the better?  Come join me this week.  I’ll be speaking about Ketogenic BioHacking,  Thursday, March 31st, in Scottsdale, Arizona.  Meet me from 7-8:30pm and learn how to improve fat burning, bio-hack your epi-genetic metabolism for improved blood sugar, cholesterol, blood pressure and so much more . . .

You’ll also get to meet Kim Minert who will be signing her new book, Burn Fat for Fuel.  And, you’ll get a chance to meet the amazing Abigail Epps-Kluttz, body builder, fitness model & Pruvit Ambassador.

You can sign up at the Eventbrite link here. I look forward to seeing you!!

Ketogenic Rule #7: Abs are Made in the Kitchen – Not the Gym

Abs female Abs made in kitchen

“Doc, how do I get six-pack abs?”

I get this question almost daily. Sorry to burst your bubble, but there is NO exercise program that will give you “six-pack” abs.

Really.  You can do sit-ups, leg lifts and crunches ’till the cows come home and it will do nothing other than give you abdominal cramps.  It will also make you hungry.  I don’t care what Men’s Fitness, Bodybuilding.com, Muscle Magazine, Shape or even Doctor Oz said. There are no “6 Best Exercises for Ripped Abs.”  There is only one exercise . . . throwing the carbs in the trash (or giving them to the neighbor you don’t like.)

The “12 Step Ab Program” really only has ONE STEP . . . cut the carbs.  Let me repeat that.  There is only ONE STEP to “six-pack abs,” . . . cut the carbs.  Cardiovascular exercise does nothing for amazingly toned abdominal muscles, other than make you hungry.   Resistance exercise improves insulin resistance, but doesn’t build the abs.  Avoiding the milk, rice, wheat, oatmeal and fruit allows the abs to appear.  Yes, I’m serious.  What do bears eat? Berries.

When did you last see the a bear with “six-pack abs?”

The only way to see your “six-pack” is to remove the fat covering your “six-pack.”  The only way to get rid of fat covering your “six-pack” is to stop drinking it and lower the carbohydrate content to less than 20 grams per day.  Seriously . . .

So you’ve done 100 crunches a day for six months?  Do you see your “six-pack” now?  Exactly.

I’ve said it before and I’ll say it again.  Insanity is doing the same thing over and over and expecting a different result.

Follow the principles outlined in my past articles like The Principle Based Ketogenic Lifestyle . . . Part I & Ketogenic Principles . . . Part II and make sure you are avoiding Common Ketosis Killers.

Dr. Nally’s Favorite Exogenous Ketones

Staying in ketosis and adding 2-3 days of resistance training will melt 2-5 lbs of abdominal fat away each month.   Yes, I know it is slow . . . but that is weight (fat) that will stay off.  Use whole foods high in fat, moderate in protein and low in carbohydrate.  Use supplements like Keto//OS & Adapt bars to help when you don’t have access to a good meal or as a snack when you are hungry.  Look at the list of Low Carb Links above to get great ideas for meal preparation and sweeteners that you can use.

 

Adapt Your Life

 

 

Random Thoughts from the Toilet Paper Roll

Random-Thought-Notebook

I am a family physician.  Each door I open holds another challenge, another question or another puzzle. You never know what will be behind door number 2 or number 3.  This leads to becoming very adept at understanding and thinking about the random.  Door #1 one holds the rash. Door #2 holds the patient with diabetes.  Door #3 . . . rectal bleeding.  Yes, my morning often starts out just that way.

While randomly thinking about the randomness that my career choice brought to my life, I’ve made a few random decisions that relate to our health in general.

Smedbo CS3414 Cabin Euro-Style Toilet Roll With Lid Toilet Roll

First, if I ever decide to buy a toilet paper roll company, I’ve already made the executive decision that each piece of paper on the roll needs the opportunity to express itself in a random way. One piece would say, “Nice fingernail polish.” Another would say, “Wow, you have a nice bottom.”  A third would say, “Please don’t apologize, brown is my favorite color.” A fourth might say, “You know, you really should see your doctor about that . . . ”

If I Get Hit By a Bus Tomorrow, Here's How to Replace the Toilet Paper Roll

Second, if I live until I’m 70 years old, I will have spent 10 of those years on Monday.  This calls for sausage and eggs for breakfast every Monday morning.  Wait, I’m already doing that . . . no wonder I like Mondays.  It also means that if I set my clock to wake up earlier on the weekend, then Monday morning I will start the week off “sleeping in.” It is amazing to me that even under ideal conditions people have trouble locating their car keys in a pocket, finding their cell phone, and even pinning the tail on the donkey . . . but I’d bet everyone of us can find & push the SNOOZE button from 3 feet away, in about 1.7 seconds, eyes closed, first time, every time…

Dok CR32 4 Port Smart Phone Charger with Speaker, Alarm, Clock & FM Radio

Third, with all of this randomness . . . someone needs to invent the “Sarcasm Font.” There are some things that shouldn’t be written in “Times New Roman.”

Fourth, Can I take back all those times I didn’t want to take a nap when I was younger?  I am quite convinced that a significant number of my obesity patient’s would be so much more successful with an afternoon nap.

Fifth, in the age of computers, voice recognition, iPhones and electronic medical records, I really want to meet the person that invented cursive and ask, “Was that really necessary?”

Sixth, in this new era of reality everything, I think that print newspapers would still be fascinatingly successful if the obituary column told you how the person died.

KetoOS
KetoOS – Drinkable Exogenous Ketones

Seventh, with all the high fat, moderate protein I recommend, the freezer has become an important appliance in the ketogenic world . . .yet no one can answer me this question: “Why is there still no freezer light?”

Are the Keys in the Freezer?

Last, bad decisions often make for the best stories. . . .

 

The Low-Carb Restaurant

Ketogenic Lifestyle Rule #1: There should ALWAYS be bacon in the fridge

BaCoN Fridge

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!
Adapt Your Life

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!

 

Links referenced in this video:

Red & Processed Meats: Bacon Fear-Mongering

Calculating Your Protein Needs from Ideal Body Weight

The Power of a Good Vitamin

 

(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.)

Patience: Why Weight Loss is a Slow Process?

tortoise_&amp;_hare_1

Watch this weekend’s Periscope conversation about why weight loss is slow and why anything that is worthwhile takes time.

You can watch the Periscope Video below:

Is Your Sweetener Making you FAT?

old-man-sour-face

I am frequently asked about the sweeteners that can be used with a low carbohydrate diet.  There are a number of sweeteners available that are used in “LowCarb” pre-processed foods like shakes or bars, or in cooking as alternatives to sugar; however, many of them raise insulin levels without raising blood sugar and are not appropriate for use with a true low-carbohydrate/ketogenic diet.  You can see and print the article I published clarifying which sweeteners you can use and which ones to avoid in the menu bar above “Sour Truth About Sweeteners” and you can watch last night’s periscope below:

Enjoy!!

 

Low-Carb Recipes: Candied Nuts & Death By Chocolate Cheese Cake

Catch up with Dr. Nally and his amazingly beautiful and talented wife, Tiffini, as he Periscopes about two of his favorite Low-Carb snacks:

Enjoy!

 

Thinking Outside of the Box

Nine dots

The image above has nine dots within a square.  Your task, using only four lines is to connect ALL nine dots WITHOUT ever raising your pen, pencil or finger (Please don’t use a sharpie on your computer screen . . . it doesn’t come off).

You may have seen this puzzle previously . . . it’s made its rounds in corporate training circles. But the underlying principle remains true.  The solution requires you to expand your thinking or to “think outside the box.”out-of-the-box

Whenever you find yourself on the side of the majority, it is time to pause and reflect. (Mark Twain)

Why should we limit ourselves to thinking outside the box.  Can’t we just get rid of the box?

True discovery consists in seeing what everyone has seen . . . then, thinking what no one has thought.

The answer can be found when those four lines are used beyond the box our mind creates:

Nine dots solution

What good has the box done us?  People were burned at the stake because they refused to believe the Earth was not the center of the universe. People were beheaded because they had a sneaking suspicion that the world was not flat.

Why is it so very hard to accept that our weight gain and diabetes are driven by a hormonal signal, and not by gluttony or caloric intake of fat?  The definition of insanity is doing the same thing repetitively and expecting a different outcome.  How long have you been restricting calories and fat with only minimal or no improvement in your weight, blood sugar, cholesterol or general feeling of health?diabetes global warming

The main problem with the current thought model, or dogma, on the obesity’s cause is that it does not account for metabolic syndrome.  Metabolic syndrome is insulin resistance.  It is an over production of insulin in the presence of ANY form of carbohydrate (sugar or starch).

In the practice of medicine over the last 15 years, I noticed that a very interesting pattern emerged.  There was always a spike in fasting and postprandial insulin levels 5-10 years prior to the first abnormal fasting and postprandial blood sugars.  These patients were exercising regularly and eating a diet low in fat.  But they saw continued weight gain and progressed down the path of metabolic syndrome.  10-15 years later, they fall into the classification of type II diabetes.  What I now lovingly refer to as stage IV insulin resistance.

The only thing that seems to halt this progressive process with any degree of success is carbohydrate restriction.  Fasting insulin levels return to normal, weight falls off, and the diseases of civilizations seem to disappear as insidiously as they arose.

So you tell me, is the world flat?  Is the Earth the center of the universe?

Low-carb is bad

What is a low carbohydrate or ketogenic diet?  15 years of practical in the trenches experience have helped me develop a very simple program to help you lose and maintain your weight.  Access to this program, video help and access to blog articles at your fingertips are offered through my online membership site.

You can also hear me each week a I discuss low carbohydrate, paleolithic and ketogenic diets with the Legendary Jimmy Moore on KetoTalk.com

Vote for Jenna!

lcc-header3160

Our very own, Jenna Lightfoot, PA-C, made it into the Cohost Contest Final Round for Jimmy Moore’s Low Carb Conversations.  Listen to this intriguing review of the recent headlines and vote for your favorite candidate here.

LowCarbConversations Final Round

At Nally Family Practice, where Jenna is one of our in-house Paleo/Low Carb experts, we thought that they all did a fantastic job. However, we’re a little preferential on who won this final round.

But, you should be the judge.  So, click the link here, or down load the podcast from iTunes and make sure you vote ASAP!

 

Get Ready For KetoTalk with Jimmy & the Doc!

KetoTalk

KetoTalk with Jimmy & the Doc (the legendary podcaster Jimmy Moore from Livin’ La Vita Low Carb and his newest co-host, your’s truly, Dr. Adam Nally) makes its debut this Thursday, December 31st, 2015 on iTunes.  You can see the show notes at KetoTalk.com (will be up and live on January 1st, 2016).

Throughout the exciting month of January, we will be airing a brand new episode of this 20-minute show each Thursday and a special bonus episode available on Sundays just to wet your ketogenic appetite and to kick off the podcast in its first month. Then, in February we’ll settle in to our regular Thursday time slot each week.

New podcasts can take a few days to assimilate into ‪#iTunes, so don’t get discouraged if you don’t immediately see it up on iTunes. However, you can always find them at KetoTalk.com.  Jimmy and I look forward to being your go-to, Ketogenic Lifestyle source for the latest and greatest in treating the diseases of civilization!

Get a sneak peek of our new show on tomorrow’s (Wednesday, December 30th) episode of “The Livin’ La Vida Low-Carb Show” where you can hear my interview with Jimmy as a preview what is sure to be a big hit in the ‪#‎keto‬ community. Thanks in advance for supporting our new podcast!

Definition of Insanity: Cutting Calories/Restricting Fat & Expecting Weight Loss

Have you been cutting your calories and reducing fat and exercising your brains out and still not seeing the needle on the scale move that much?  Persistently and repetitively performing an action that doesn’t produce the desired result is insanity.  Cutting calories and reducing fat while expecting weight loss is akin to pouring water in the gas tank of your car and expecting it to run smoothly. Why do we do it? Are the 53, 000, 000 people with health club and gym memberships this year really insane?

This evening on PeriScope we touch on fat phobic insanity  and the limiting step that actually turns weight gain on or off. (We knew about this in the 1960’s, we just ignored it.)

You can see tonight’s PeriScope with the rolling chat-box questions here at Katch.me/docmuscles.  Or, you can watch the video stream below:

The only way to successfully loose weight is to modify or turn off the mechanisms that stimulate fat storage.  For years we have been told that this was just a problem of thermodynamics, meaning the more calories you eat, the more calories you store. The solution was, thereby, eat less calories or exercise more, or both. We are taught in school that a 1 gram of carbohydrate contains 4 kcal, 1 gram of protein contains 4 kcal, and 1 gram of fat contains 9 kcal.

If you ascribe to the dogma that weight gain or loss is due to thermodynamics, then it’s easy to see that cutting out fat (the largest calorie containing macro-nutrient) would be the best way limit calories.  For the last 65 years, we as a society have been doing just that, cutting out fat, exercising more (with the idea of burning off more calories) and eating fewer calories.

What has this dogma done for us? It’s actually made us fatter! (1)

World Obesity Rates
Obesity Rates Around the World

Some may argue that we really aren’t eating fewer calories and exercising more. But most people I have seen in my office have tried and tried and tried and failed and failed and failed to loose weight with this methodology. In fact, the majority of my patients attempt caloric restriction, exercise and dieting multiple times each year with no success. The definition of insanity is “doing the same thing over and over and expecting a different result.”

Most of my patients are not insane, they recognize this and stop exercising and stop restricting calories . . . ’cause they realized, like I have, that it just doesn’t work!

If you’re one that is still preaching caloric restriction and cutting out fat, I refer you to the figure above and the definition of insanity . . . your straight-jacket is in the mail.

So, if reducing the calories in our diet and exercising more is not the mechanism for turning on and off the storage of fat, then what is?

Before I can explain this, it is very important that you appreciate the difference between triglycerides and free fatty acids.  These are the two forms of fat found in the human body, but they have dramatically different functions.  They are tied to how fat is oxidized and stored, and how carbohydrates are regulated.

Fat stored in the adipose cells (fat cells) Triglycerides-and-Glycerol1as well as the fat that is found in our food is found in the form of triglycerides. Each triglyceride molecule is made of a “glyceride” (glycerol backbone) and three fatty acids (hence the “tri”) that look like tails. Some of the fat in our adipose cells come from the food we eat, but interestingly, the rest comes from carbohydrates

(“What! Fat comes from sugar?! How can this be?!!“)

de novo lipogenesis
De Novo Lipogenesis

We all know that glucose derived from sugar is taken up by the cells from the blood stream and used for fuel, however, when too much glucose is in the blood stream or the blood sugar increases above the body’s comfort zone (60-100 ng/dl), the body stores the excess. The process is called de novo lipogenesis, occurring in the liver and in the fat cells themselves, fancy Latin words for “new fat.”  It occurs with up to 30% (possibly more if you just came from Krispy Kream) of the of the carbohydrates that we eat with each meal.  De novo lipogenesis speeds up as we increased the carbohydrate in our meal and slows down as we decrease the carbohydrate in our meal. We’ve known this for over 50 years, since it was published by Dr. Werthemier in the 1965 edition of the Handbook of Physiology (2).

While we know that fat from our diet and fat from our food is stored as triglyceride, it has to enter and exit the fat cell in the form of fatty acids.  They are called “free fatty acids” when they aren’t stuck together in a triglyceride.  In their unbound state, they can be burned as fuel for the body within the cells. I like to think of the free fatty acids as the body’s “diesel fuel” and of glucose as the body’s version of “unleaded fuel.”  The free fatty acids can easily slip in and out of the fat cell, but within the adipose cell, they are locked up as triglycerides and are too big to pass through the cell membranes.  Lipolysis is essentially unlocking the glycerol from the free fatty acids and allowing the free fatty acids to pass out of the fat cell. Triglycerides in the blood stream must also be broken down into fatty acids Insulin and Triglyceridesbefore they can be taken up into the fat cells. The reconstitution of the fatty acids with glycerol is called esterification. Interestingly, the process of lipolysis and esterification is going on continuously, and a ceaseless stream of free fatty acids are flowing in and out of the fat cells.  However, the flow of fatty acids in and out of the fat cells depends upon the level of glucose and insulin available. As glucose is burned for fuel (oxidized) in the liver or the fat cell, it produces glycerol phosphate. Glycerol phosphate provides the molecule necessary to bind the glycerol back to the free fatty acids. As carbohydrates are being used as fuel, it stimulates increased triglyceride formation both in the fat cell and in the liver, and the insulin produced by the pancreas stimulates the lipoprotein lipase molecule to increased uptake of the fatty acids into the fat cells (3).

So when carbohydrates increase in the diet, the flow of fat into the fat cell increases, and when carbohydrates are limited in the diet, the flow of fat out of the fat cells increases.

Summarizing the control mechanism for fat entering the fat cell:

  1. The Triglyceride/Fatty Acid cycle is controlled by the amount of glucose present in the fat cells (conversion to glycerol phosphate) and the amount of insulin in the blood stream regulating the flow of fatty acid into the fat cell
  2. Glucose/Fatty Acid cycle or “Randle Cycle” regulates the blood sugar at a healthy level.  If the blood glucose goes down, free fatty acids increase in the blood stream, insulin decreases, and glycogen is converted to glucose in the muscle and liver.

These two mechanisms ensure that there is always unleaded (glucose) or diesel fuel (free fatty acids) available for every one of the cells in the body. This provides the flexibility to use glucose in times of plenty, like summer time, and free fatty acids in times of famine or winter when external sources of glucose are unavailable.

The regulation of fat storage, then, is hormonal, not thermodynamic. Unfortunately, we’ve know this for over 65 years and ignored it.

We’ve ignored it for political reasons, but that’s for another blog post . . .

References:

1. James, W. J Intern Med, 2008, 263(4): 336-352

2. Wertheimer, E. “Introduction: A Perspective.” Handbook of Physiology. Renold & Cahill. 1965.

3. Taubs, G. “The Carbohydrate Hypothesis, II” Good Calorie, Bad Calorie. Random House, Inc. 2007, p 376-403.

Pre-, Post-Workout Meal on Ketosis. Is it Important?

Today’s Periscope was an exciting one.  Do you really need a pre- or post-workout shake or meal?  How much protein do you need?  What’s the difference between ketosis and ketoacidosis?  Is Dr. Nally a ketogenic cheerleader? Get your answers to these and many more questions asked by some wonderful viewers this evening on today’s PeriScope.

https://katch.me/embed/v/5def6bce-4f67-363a-b5f9-3bbec8a8aea2?sync=1

Be sure to check out Dr. Nally’s new podcast called “KetoTalk with Jimmy and the Doc” with the veteran podcaster Jimmy Moore on KetoTalk.com.  The first podcast will be available on December 31, 2015.  KetoTalk with Jimmy and the Doc will be available for download for free on iTunes.

Stay tuned . . . !

The 3 Weight Loss Necessities to Weathering the Holidays

What are the three things you need to successfully weather the holidays with your ketosis lifestyle? What does a raindeer on a motorcycle look like? How does insulin resistance effect kidney stones and gout? How do you get back on track if you fall off the ketosis wagon? These and many more questions are answered by Dr. Adam Nally on tonight’s PeriScope.

You can see the video stream including the comment roll here at katch.me/docmuscles.  Or you can watch the video below:

Caffeine . . . Weight Loss Wonder Boy or Sneaky Scoundrel?

I’ve been looking for the answer for quite some time. . . what role does caffeine play in your and my weight management journey?  The answer gave me a headache. . . literally and figuratively.

As many of you, including my office staff, know, I love my Diet Dr. Pepper (and my bacon).  I found that being able to sip on a little soda throughout the day significantly helped the carbohydrate cravings and munchies during a busy and stressful day at the office.   Diet Dr. Pepper contains caffeine, however, I wasn’t really worried.  Caffeine has been well know to have a thermogenic effect which increases your metabolism and has been thought for many years to help with weight loss among the weight loss community.

Diet Dr. Pepper is, also, one of only four diet sodas on the grocery store shelves that doesn’t contain acesulfame potassium (click here to see why most artificial sweeteners cause weight gain).  The four diet sodas that I have been comfortable with my patients using are Diet Dr. Pepper, Diet Coke, Diet Mug Root-beer and Diet A&W Cream Soda.  These are the last four hold out diet sodas that still use NutraSweet (aspartame) as the sweetener.  Most of the soda companies have switched the sweetener in their diet sodas to the insulinogenic acesulfame potassium because it tastes more natural and aspartame has been given a media black eye of late.  However, NutraSweet (aspartame) is the only sweetener that doesn’t spike your insulin or raise blood sugar (click here to find out why that is important).

Yes, I know.  The ingestion of 600 times the approved amount of aspartame causes blindness in lab rats (but we’re not lab rats, and . . . have you ever met someone that drinks 600 Diet Dr. Peppers in a day?  The lethal dose of bananas, which are high in potassium that will stop your heart, is 400).  Aspartame can also exacerbate headaches in some (about 5% of people) and I’ve had a few patients with amplified fibromyalgia symptoms when they use aspartame.   But for most of us, its a useful sweetener that doesn’t spike your insulin response, halting or causing weight gain.

But, over the last few years, I’ve noticed that increased amounts of Diet Dr. Pepper & Diet Coke seem to cause plateauing of weight and decreasing the ability to shift into ketosis, especially mine.  I’ve also noticed (in my personal n=1 experimentation) that my ability to fast after using caffeine regularly seems to be less tolerable, causing headaches and fatigue 8-10 hours into the fast, symptoms that don’t seem to let up until eating. Through the process of elimination, caffeine seems to be the culprit.

Red Bull in caffeineAfter mulling through the last 10 years of caffeine research, most of which were small studies, had mixed results, used coffee as the caffeine delivery system (coffee has over 50 trace minerals that has the potential to skew the results based on the brand) and never seemed to ask the right questions, the ink from a study in the August 2004 Diabetes Care Journal screamed for my attention.

It appears that caffeine actually stimulates a glucose and insulin response through a secondary mechanism.   The insulin surge and glucose response is dramatically amplified in patients who are insulin resistant.  Caffeine doesn’t effect glucose or insulin if taken while fasting; however, when taken with a meal, glucose responses are 21% higher than normal, and insulin responses are 48% higher in the insulin resistant patient. Caffeine seems to only effect the postprandial (2 hours after a meal) glucose and insulin levels.  The literature shows mixed responses in patients when caffeine is in coffee or tea, probably due to the effect of other organic compounds (1).

Caffeine Effect on glucose insulin
Caffeine effect on plasma glucose and plasma insulin compared to placebo (1).

Caffeine also diminishes insulin sensitivity and impairs glucose tolerance in normal and already insulin resistant and/or obese patients.  This is seen most prominently in patients with diabetes mellitus type II (stage IV insulin resistance).  Caffeine causes alterations in glucose homeostasis by decreasing glucose uptake into skeletal muscle, thereby causing elevations in blood glucose concentration and causing an insulin release (2-6).

Studies show that caffeine causes a five fold increase in epinephrine and a smaller, but significant, norepinephrine release.  The diminished insulin sensitivity and exaggerated insulin response appears to be mediated by a catacholamine (epinephrine, norepinephrine & dopamine)  induced stress response (5).  Caffeine has a half life of about 6 hours, that means the caffeine in your system could cause a catacholamine response for up to 72 hours depending upon the amount of caffeine you ingest (7).

The reason for my, and other patient’s, headaches and fatigue after a short fast was due to the exaggerated stress hormone response.  Increased levels of insulin were induced by a catacholamine cascade after caffeine ingestion with a meal, dramatically more amplified in a person like me with insulin resistance. The caffeine with the last meal cause hypoglycemia 5-7 hours into the fasting, leading to headaches and fatigue that are only alleviated by eating.

Even when not fasting, the caffeine induced catacholamine cascade causes up to 48% more insulin release with a meal, halting weight loss and in some cases, causing weight gain.

Caffeine is not the “Wonder-Boy” we thought it was.

How much caffeine will cause these symptoms? 50 mg or more per day can have these effects.

caffeine-content-of-popular-drinks

Ingestion of caffeine has the following effects:

  • 20-40 mg – increased mental clarity for 2-6 hours
  • 50-100 mg – decreased mental clarity, confusion, catacholamine response
  • 250-700 mg – anxiety, nervousness, hypertension & insomnia
  • 500 mg – relaxation of internal anal sphincter tone (yes . . . you begin to soil yourself)
  • 1000 mg – tachycardia, heart palpitations, insomnia, tinnitus, cognitive difficulty.
  • 10,000 mg (10 grams) – lethal dose (Yes, 25 cups of Starbucks Coffee can kill you)

The equivalent of 100 mg of in a human was given to a spider, you can see the very interesting effect on productivity.  How often does the productivity of the day feel like the image below?

Spider Normal
Normal Spider (9)
Spider Caffeine
Spider on caffeine (9)

Beware that caffeine is now being added to a number of skin care products including wrinkle creams and makeup.  Yes, caffeine is absorbed through the skin, so check the ingredients on your skin care products.

Diet Dr. Pepper, my caffeine delivery system of choice, has slightly less caffeine (39 mg per 12 oz can or 3.25 mg per oz) than regular Dr. Pepper.  I found myself drinking 2-3 liters of Diet Dr. Pepper per day (long 16-18 hour work days in the office).  After doing my research, I realized that my caffeine tolerance had built up to quite a significant level (230-350 grams per day).

So, a few weeks ago, I quit . . . cold turkey.

Did I mention the 15 withdrawal symptoms of caffeine? (8)

  • Headache – behind the eyes to the back of the head
  • Sleepiness – can’t keep your eyes open kind of sleepiness
  • Irritability – everyone around you thinks you’ve become a bear
  • Lethargy – feels like your wearing a 70 lb lead vest
  • Constipation – do I really need to explain this one?
  • Depression – you may actually feel like giving up on life
  • Muscle Pain, Stiffness, Cramping – feel like you were run over by a train
  • Lack of Concentration – don’t plan on studying, doing your taxes or performing brain surgery during this period
  • Flu Like Illness – sinus pressure and stuffiness that just won’t clear
  • Insomnia – you feel sleepy, but you can’t sleep
  • Nausea & Vomiting – You may loose your appetite
  • Anxiety – amplified panic attacks or feeling like the sky is falling
  • Brain Fog – can’t hold coherent thoughts or difficulty with common tasks
  • Dizziness – your sense of equilibrium may be off
  • Low Blood Pressure & Heart Palpitations – low pressure and abnormal heart rhythm

I experienced 13 of the 15 that lasted for 4 days.   I do not recommend quitting cold turkey unless you have a week off and someone to hold your hand, cook your meals and dose your Tylenol or Motrin.  My wife thought I was dying. . . I thought I was dying on day two.  I actually had a nightmare about buying and getting into my own coffin.  It can take up to three weeks to completely recover from caffeine withdrawal.

The other way to quit is to decrease your caffeine intake by 50 mg every two days.   That means decrease caffeine by:

  • 1 can of soda every two days
  • 1/4 cup of coffee every day
  • 1/2 can of Energy Drinks every two days
  • 1 cup of tea every two days

The benefit of this method is that withdrawal symptoms are much less severe without the caffeine headache and the ability to remain productive.  It will take longer, but quitting cold turkey is not a pretty picture.  Been there . . . done that, . . . and I’m not going back. I actually lost another half inch off my waistline by day 5 of caffeine discontinuation.

What is the take home message here?  If you have any degree of insulin resistance, caffeine makes it worse and will amplify your weight gain as well as decrease the productivity of your day.

References:

  1. Lane JD, Barkauskas CE Surwit RS, Feinglos MN, Caffeine Impairs Glucose Metabolism in Type II Diabetes, Diabetes Care August 2004 vol. 27 no. 8 2047-2048; doi:10.2337/diacare.27.8.204
  2. Jankelson OM, Beaser SB, Howard FM, Mayer J: Effect of coffee on glucose tolerance and circulating insulin in men with maturity-onset diabetes. Lancet 1527–529, 1967
  3. Graham TE, Sathasivam P, Rowland M, Marko N, Greer F, Battram D: Caffeine ingestion elevates plasma insulin response in humans during an oral glucose tolerance test. Can J Physiol Pharmacol 79:559–565, 2001
  4. Greer F, Hudson R, Ross R, Graham T: Caffeine ingestion decreases glucose disposal during a hyperinsulinemic-euglycemic clamp in sedentary humans.Diabetes 50:2349–2354, 2001
  5. Keijzers GB, De Galan BE, Tack CJ, Smits P: Caffeine can decrease insulin sensitivity in humans. Diabetes Care 25:364–369, 2002
  6. Petrie HJ, et al. Caffeine ingestion increases the insulin response to an oral-glucose-tolerance test in obese men before and after weight loss. American Society for Clinical Nutrition. 80:22-28, 2004
  7. Evans SM, Griffiths RR, Caffeine Withdrawal: A Parametric Analysis of Caffeine Dosing Conditions, JPET April 1, 1999 vol. 289no. 1 285-294
  8. Noever R, Cronise J, Relwani RA. Using spider-web patterns to determine toxicity. NASA Tech Briefs April 29,1995. 19(4):82. Published in New Scientist magazine, 29 April 1995

How Do You Know if You’re Insulin Resistant?

How do you know if you're insulin resistant? What questions need to be asked? What should your numbers be? And, many other great ketosis questions. Also, why does Dr. Nally look like he has dirt on his chin? See it here . . .

Read more

Common Ketosis Killers

“I’ve tried your low-carb diet, Dr. Nally, and it didn’t work.”

“Hmm . . . really?”  If you’re mumbling this to yourself, or you’ve said it to me in my office, then lets have a little talk.  You’ve probably been subjected to the common ketosis killers.

Scale HelpI’ve heard this statement before.  It’s not a new statement, but it’s a statement that tells me we need to address a number of items.  If you’ve failed a low carbohydrate diet, I’d suspect you are pretty severely insulin resistant or hyperinsulinemic.  You probably never really reached true ketosis.   I’d want to have you checked out by your doctor to rule out underlying disease like hypothyroidism, diabetes, other hormone imbalance, etc.

Nutritional Ketosis is Most Effective as a Lifestyle Change

Next, switching to a low-carbohydrate lifestyle is literally a “lifestyle change.”  It requires that you understand a few basic ketosis principles.  And, it takes the average person 3-6 months to really wrap their head around what this lifestyle means . . .  and, some people, up to a year before they are really comfortable with how to eat and function in any situation.

I assume, if you are reading this article, that you’ve already read about ketosis and understand the science behind it.  If not, please start your reading with my article The Principle Based Ketogenic Lifestyle – Part I and Ketogenic Principles – Part II.  If this is the case, then please proceed forward, “full steam ahead!”

There are usually a few areas that are inadvertently inhibiting your body transformation, so let’s get a little personal.

Nutritional Ketosis is a Very Low Carbohydrate Diet

First, this is a low carbohydrate diet.  For weight loss, I usually ask people to lower their carbohydrate intake to less than 2o grams per day. How do you do that?  (A copy of my diet is accessible through my membership site HERE.)  You’ve got to begin by restricting all carbohydrates to less than 20 grams per day.  Any more than 20 to 30 grams per day will cause an insulin release from the pancreas and stimulate fat storage of both carbohydrate and fat for the next 10-12 hours, commonly killing ketosis.  Keep a dietary journal to record your progress, your cravings, your successes and failures.  I’m going to want to see it and review it with you if you see me.

No, I don’t believe in “Net Carbs.”  Net Carbs are a sales gimmick to get you to buy “artificial food” that keeps you coming back for “artificial food” and halts your weight loss (you’ll see why shortly).   You’re going to lose the most weight and feel your best when you eat real food. I do allow for the subtraction of real fiber, specifically non-cooked, non-blended, non-juiced leafy greens (If you cook, blend or juice a leafy green, it activates more carbohydrate availability).  Leafy greens are real fiber.  You can subtract them.  In fact, I recommend eating 1-3 cups of leafy greens per day to help bowel function & provide necessary folic acid, but, everything else is “carbage.”  Avoid it.

Yes, cottage cheese and yogurt contain carbohydrates.  Be very cautious with them.

No, oatmeal and Cream of Wheat™ are not helpful. See my article on Why Your Oatmeal is Killing Your Libedo.Alcohol

Alcohol also halts your weight loss.  It’s not the sugar in the alcohol I’m worried about, the distilling process changes the sugar to alcohol, however, alcohol stimulates an insulin response after the alcohol is metabolized in the liver with a SIMILAR RESPONSE to regular sugar.

 

To Effectively Maintain Nutritional Ketosis, You MUST get adequate Protein

Second, this is a low carbohydrate, moderate protein, high fat lifestyle.  N0 . . . it is NOT a high protein diet! However, so many of my patients don’t eat enough protein that they feel like it is a “high protein diet.”

Protein is essential for the building and maintaining of muscle, connective tissue and a number of other enzymatic reactions in your body.  However, in patients who are morbidly obese [people with a body mass index (BMI) over 50], excess protein intake can cause fat to be stored by producing an excessive insulin response.  In these patients we initially moderate protein.  Excess sugars and a number of proteins, in the presence of a high insulin response, are converted to triglyceride (the soft squishy stuff inside the fat cells that make them plump) and stocked away inside your adipose tissue.  Excessive protein, especially the amino acids argenine, leucine and tryptophan are common ketosis killers, not because they are converted to sugar, but because they stimulate and insulin response all by themselves.

If you don’t fall into the morbidly obese category (BMI over 50). Then, I encourage you to use the protein levels below.

Initially, I ask my patients to focus on lowering their carbohydrate intake and I don’t really worry about protein.  (It is often hard enough to figure out what the difference between a carbohydrate and a protein in the first month or two if you’ve never had any nutrition background.)  Most people begin losing weight just by lowering carbohydrates over the first few months.  Once you figure out how to lower your carbohydrates, if your weight loss is not moving and your pants are not getting looser, then you’re probably eating too much protein.

How much protein do you need?  It’s pretty easy to calculate and is based on your height and gender.  Your basic protein needs to maintain muscle, skin and hair growth are as follows:

  • 70 grams or higher for women per day
  • 120 grams or higher for men per day.

However, these levels are WAY TOO LOW for weight loss and maintaining good health.  Because we now know that protein acts as a hormone in a number of ways, in my office I recommend women get 80-90 grams of protein per day, and men should get > 150 grams of protein per day.

ProteinIf you’re still a little confused about protein, read my article on Why Your Chicken Salad Stops Your Weight Loss.

This also goes for protein powders and protein shakes.  Many of these have 25-40 grams of protein in them per serving, so be careful with their use.

Nutritional Ketosis is a High Fat Diet

Third, this is a high fat lifestyle.  Yes, I want you to INCREASE your fat intake.  I’m going to repeat that, again, just for clarity, . . . . INCREASE your fat intake.  Increase it to around 50% of your total calories, . . . 70% of your total calories if you can do it.  Not enough fat is a common ketosis killer.

“What?! Won’t that cause heart disease and stroke and make my cholesterol worse?!!!”

I know, take a big deep breath . . . (you may even need to breath into a paper bag for a minute if you begin hyperventilating).

No, it will not raise your cholesterol, cause heart disease, or cause a stroke.  If you have lowered your carbohydrate intake to less than 20 grams per day, then there is NO hormonal signal for you to make more bad cholesterol, worsen heart disease, or cause a stroke.  In fact, there is great data showing that increasing your fat and lowering your carbohydrates reverses the blockage in the arteries.  I see this reversal every single day in my clinic through the application of ketogenic diets.

If we remove carbohydrate as your primary fuel, you must replace it with something else.Food Pyramid WrongThat something else should be fat.  Protein must be moderated, as it will also be stored as fat if you eat too much.  So, if the carbohydrates are kept low, fat intake can be increased and the body will pick the fat it wants and essentially throw the rest out without raising cholesterol, causing weight gain or causing heart disease.  This is why we want you to use good natural animal fats like butter, hard cheese, olive oil, coconut oil, avocado, etc.  Look for fats highest in omega-3 fatty acids as these decrease inflammation and improved weight loss.  Look for meats highest in fat like red meat (55% fat) and pork (45% fat).  Take the food pyramid and flip it over.

Check Your Sweeteners At the Door

The fourth common ketosis killer and culprit in halting your weight loss is  artificial sweeteners.  There are quite a few of them.  Most of them WILL cause an insulin response (exactly what we don’t want for weight loss) with minimal to no rise in blood sugar.  Raising blood sugar doesn’t matter, if the insulin is being stimulated  . . . “you’re gonna gain weight for the next 10-12 hours.”  I wrote an article for you to print off and hang on your fridge, upload it to your iPhone or carry it with you in your purse to the grocery store. (If you’re a man and you’re carrying a purse, please don’t tell me about it.)  You can find the article here: The Skinny About Sweeteners.  The short list of those sweeteners that are OK to use and cook with, and do not increase insulin response, can be found here in my Amazon Store.

Don’t Even Start with Coffee Creamers

CoffeeCreamersFifth on my list is coffee creamer.  Coffee creamer contains corn syrup solids (another very special name for  . . . SUGAR!!) and/or maltodextrin (SUGAR’s married name!).  If you must put something in your coffee, then use real heavy cream (pure tasty fat) or real butter.   It will taste much better (I’m told – I don’t drink coffee personally) and you won’t get an insulin spike 2-3 hours later and begin craving more coffee and donuts.

Yes, “Half & Half” is half fat and half sugar. . .  avoid it too!!

Ketosis Killing Medications

The sixth culprit in halting weight loss is medications.  Please talk to your doctor before making ANY changes in your medications as suddently stopping them can be hazardous to your health.  Those highest on my list for stopping your weight loss are Glyburide (glipizide), insulin, & steroids like prednisone.  A more complete list of medications that will halt your weight loss can be found on my on my ketogenic diet plan.  If you are on any prescription medications, please talk to your doctor or to a physician board certified in obesity medicine treatment about how to adjust or wean these medications in a way that is safe and appropriate for your individual needs.

Estrogen

The seventh common culprit in halting weight loss is a lack of estrogen in menopausal or post-menopausal women.  About menopause-cartoon-02420% of women that I see in my practice who are over 55 years old, need some degree of estrogen replacement before they are able to lose weight.  Estrogen plays a very large role in regulation of the metabolism and when deficient, causes weight retention or weight gain.  Talk to your doctor about the risks and benefits of estrogen for you individually in this situation.

Stress

The eighth reason for shifting out of ketosis is stress.  Acute and chronic stress can be caused by a number of issues. The most common is lack of sleep.  You can read about stress and ways to address it in two of my articles: How Does Stress Cause Weight Gain? and Adrenal Insufficiency, Adrenal Fatigue and PseudoCushing’s Syndrome – Oh My!

For many years, we’ve thought that caffeine was great for weight loss.  However, we are finding, clinically, that too much caffeine can also cause a stress response by raising cortisol, releasing glycogen, thereby stimulating an insulin response and bringing your weight loss to a screeching halt.  How much caffeine? . . . The jury is still out . . . and remains to be determined.  But, I am currently under going an n=1 experiment on myself (as many of you know, I loved Diet Dr. Pepper.  But I had to give it up).  I’ll keep you posted . . .

Look closely at these eight issues.  Correcting them usually solves most plateaus with weight loss and improves blood pressure, blood sugar and cholesterol control dramatically.

Adrenal Insufficiency, Adrenal Fatigue, PseudoCushing’s Syndrome – Oh My!

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?!  Adrenal Fatigue for Dummies

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:

  1. Chronic Physical Stress
  2. Severe Bacterial or Fungal Infections that Go Untreated
  3. Malnutrition or Intense Chronic Exercise
  4. Psychological Stress – including untreated or under-treated depression, anxiety, post-traumatic stress, or dysthymia (chronic melancholy)
  5. Alcoholism

The psychiatric literature suggest that up to 80% of people with depressive disorders have increased cortisol secretion (1,2,3).  HPA Stress responsePeople 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).

HPAThyroidUnder 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:

  1. 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.
  2. Pfohl B, Sherman B, Schlechte J, Stone R. Pituitary-adrenal axis rhythm disturbances in psychiatric depression. Arch Gen Psychiatry 1985; 42:897.
  3. 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.
  4. 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.
  5. McEwen, B.S. The brain as a target of endocrine hormones. In Neuroendocrinology. Krieger and Hughs, Eds.: 33-42. Sinauer Association, Inc., Massachusetts, 1980.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Cavagnini, F., M. Croci, P. Putignano, et al. Glucocorticoids and neuroendocrine function. International Journal of Obesity 24: S77-S79, 2000.
  12. 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.
  13. 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.

The 5 Myths of Weight Loss

This evening we covered the 5 myths of weight loss identified through the National Weight Control Registry’s research findings. What causes “wrinkle face” for Dr. Nally?  We also talked about & answered 20 minutes of rapid fire questions ranging from the amount of protein you need daily to the likelihood a human could be a bomb calorimeter . . . exciting stuff!!

You can watch the video stream below.  Or you can Katch the replay with the rapid stream of exciting comments here at Katch.me/docmuscles.

What Lab Testing Do You Need to Start Your Weight Loss Journey?

What laboratory testing is necessary when you start your weight loss journey on a Ketogenic, Low-Carbohydrate, Paleolithic or any other dietary changes?  Why do you need them and what are you looking for?  We discuss these questions and others on today’s PeriScope.  Lots of questions from around the world to day . . . this one lasted a bit longer than normal . . . 45 minutes to be specific.  But it’s a good one because of all of your fantastic questions!  You really don’t want to miss this one.

You can see the video below or watch the video combined with the rolling comments here on Katch.me/docmuscles.

A list of the labs that we discussed are listed below:

  • Fasting insulin with 100 gram 2 or 3 hour glucose tolerance test with insulin assay every hour
  • CMP
  • CBC
  • HbA1c
  • Leptin
  • Adiponectin
  • C-Peptid
  • NMR Liprofile or Cardio IQ test
  • Lipid Panel
  • Urinalysis
  • Microalbumin
  • Apo B
  • C-reactive protein
  • TSH
  • Thyroid panel
  • Thyroid antibodies
  • AM Cortisol

This list will at least get one started, provide the screening necessary to identify insulin resistance (Diabetes In-Situ), Impaired fasting glucose, diabetes and allow for screening for a number of the less common causes of obesity.

I would highly recommend that you get these through your physician’s office so that appropriate follow up can be completed.  These labs will need to be interpreted by your physician, someone who understands and is familiar with various causes of obesity.

Until next time . . .

 

Diabetes Mellitus – Really the Fourth Stage of Insulin Resistance

Diabetes Epidemic &amp; You

I just completed my reading of Dr. Joseph Kraft’s Diabetes Epidemic & You.  This text originally printed in 2008 and was re-published in 2011.  I am not really sure why I have never seen this book until now, but I could not put it down.  I know, I am a real life medical geek.  But seriously, you should only read this book if you are concerned about your health in the future. Otherwise, don’t read it.

For the first time in 15 years, someone has published and validated what I have been seeing clinically in my office throughout my career.  Dr. Kraft is a pathologist that began measuring both glucose and insulin levels through a three hour glucose tolerance blood test at the University of Illinois, St. Joseph Hospital in Chicago.  This test consists of checking blood sugar and insulin in a fasted state, and then drinking a 100 gram glucose load followed by checking blood sugar and insulin at the 30, 60, 120 and 180 minute marks (a total of three hours).

Dr. Kraft completed and recorded this test over a period of almost 30 years on 14,384 patients between 1972 and 1998. His findings are landmark and both confirm and clarify the results that I have seen and suspected for years.

Type II Diabetes: Really Just the Fourth Stage of Diabetes

I am convinced that our problem with treating obesity, diabetes and the diseases of civilization has been that we defined diabetes as a “disease” based on a lab value and a threshold instead of identifying the underlying disease process.  We have been treating the symptoms of the late stage of a disease that started 15 to 20 years before it is ever actually diagnosed. Diabetes is defined as two fasting BS >126, any random blood sugar >200, or a HbA1c >6.5%.  (Interestingly this “disease” has been a moving target.  When I graduated from medical school it was two fasting blood sugars >140 and the test called hemoglobin A1c (HbA1c) that we use today for diagnosis didn’t even exist).  The semantics associated with this problem is that many of us recognize that the disease is not actually diabetes. The disease is (as far as we understand it today) insulin resistance or hyperinsulinemia.   This is where Dr. Kraft’s data is so useful.  Diabetes, as it is defined above, is really the fourth stage of insulin resistance progression over a 15-20 year period and Dr. Kraft’s data presents enormous and very clear evidence to that effect.

insulin-resistance-obesity

When I first entered private practice 15 years ago, I noticed a correlation and a very scary trend that patients would present with symptoms including elevated triglycerides, elevated fasting blood sugar, neuropathy, microalbuminuria, gout, kidney stones, polycystic ovarian disease, coronary artery disease and hypertension that were frequently associated with diabetes 5-15 years before I ever made the diagnosis of diabetes mellitus.  I began doing 2 hour glucose tolerance tests with insulin levels and was shocked to find that 80-85% of those people were actually diabetic or very near diabetic in their numbers. The problem with a 2 hour glucose tolerance test, is that if you are diabetic or pre-diabetic, you feel miserable due to the very profound insulin spike that occurs.  A few patients actually got quite upset with me for ordering the test, both because of how they felt after the test, and the fact that I was the only physician in town ordering it.  So, in an attempt to find an easier way, I found that the use of fasting insulin > 5 nU/dl, triglycerides > 100 mg/dl and small dense LDL particle number > 500 correlated quite closely clinically with those patients that had positive glucose tolerance tests in my office.  There is absolutely no data in the literature about the use of this triangulation, but I found it to be consistent clinically.

I was ecstatic to see that Dr. Kraft plowed through 30 years and over 14,000 patients with an unpleasant glucose tolerance test and provided the data that many of us have had to clinically triangulate.  (I’m a conservative straight white male, but if Dr. Kraft would have been sitting next to me when I finished the book this afternoon, I was so excited that I probably would have kissed him.)

Insulin resistance or hyperinsulinemia (the over production of insulin between 2-10 times the normal amount after eating carbohydrates) is defined as a “syndrome” not a disease.  What Dr. Kraft points out so clearly is that huge spikes in insulin occur at 1-2 hours after ingestion of carbohydrates 15-20 years prior to blood sugar levels falling into the “diabetic range.”   He also demonstrates, consistently, the pattern that occurs in the normal non-insulin resistant patient and in each stage of insulin resistance progression.

The information extrapolated from Dr. Kraft’s research give the following stages:

Stages of Insulin Resistance
Stages of insulin resistance by 3 hr OGTT extrapolated from “Diabetes Epidemic & You”

From the table above, you can see that the current definition of diabetes is actually the fourth and most prolifically damaging stage of diabetes.  From the data gathered in Dr. Kraft’s population, it is apparent that hyperinsulinemia (insulin resistance) is really the underlying disease and that diabetes mellitus type II should be based upon an insulin assay instead of an arbitrary blood sugar number. This would allow us to catch and treat diabetes 10-15 years prior to it’s becoming a problem.  In looking at the percentages of these 14,384 patient, Dr. Kraft’s data also implies that 50-85% of people in the US are hyperinsuliemic, or have diabetes mellitus “in-situ” (1). This means that up to 85% of the population in the U.S. is in the early stages of diabetes and is the reason 2050 projections state that 1 in 3 Americans will be diabetic by 2050 (2).

Insulin resistance is a genetically inherited syndrome, and as demonstrated by the data above has a pattern to its progression.  It is my professional opinion that this “syndrome” was, and actually is, the protective genetic mechanism that protected groups of people and kept them alive during famine or harsh winter when no other method of food preservation was available. It is most likely what kept the Pima Indians of Arizona, and other similar groups, alive while living for hundreds of years in the arid desert. This syndrome didn’t become an issue among these populations until we introduced them to Bisquick and Beer.

The very fascinating and notably exciting aspect of this whole issue is that insulin resistance is made worse by diet and it is completely treatable with diet. This is where the low carbohydrate diet, and even more effective ketogenic diet or lifestyle becomes the powerful tool available.  Simple carbohydrate restriction reverses the insulin spiking and response.  In fact, I witness clinical improvement in the insulin resistance in patients in my office over 18-24 months every day.  You can get a copy of my Ketogenic Diet here in addition to video based low carbohydrate dietary instruction.

Until we are all on the same page and acknowledge that diabetes is really the fourth stage of progression on the insulin resistance slippery slope, confusion and arguments about treatment approaches will continue to be ineffective in reducing the diseases of civilization.

References:

  1. Kraft, JR. Diabetes Epidemic & You: Should Everyone Be Tested? Trafford Publishing, 2008, 2011. p 1-124
  2. Boyle JP et al. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence,  http://www.pophealthmetrics.com/content/8/1/29 Accessed November 22, 2015

How to Stay Motivated on Carbohydrate Restriction

This evening on PeriScope, we talked about the 10 things you can do to stay motivated on your low-carb lifestyle.  A number of great questions were asked including:

  • How much carbohydrate should be restricted?
  • What labs should you be monitoring regularly?
  • What’s a normal blood sugar?
  • Why is Dr. Nally freezing in Denver?
  • Is fermented food good for you?
  • Why should you eat pickles and kimchi even when you’re not pregnant?

And, much much more . . . It’s like a college ketogenic course on overdrive . . . for FREE!!!

You can see the PeriScope with the comments rolling in real-time here: katch.me/docmuscles

Or, you can watch the video stream below:

See you next time.

Chewing the Phat with Dr. Nally (The Psychology of Fat & Many Other Questions)

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:

Thanks for visiting!!!

How Fat Makes You Skinny . . . (Eating Fat Lowers Your Cholesterol?!)

Diseases seem to arrive in three’s each day in my office.  Today I had three different patients with cholesterol concerns who were notably confused about what actually makes the cholesterol worse, and what causes weight gain.  Each of them, like many patients that I see, were stuck in a state of confusion between low fat and low carbohydrate lifestyle change.   My hope is to give my patients and anyone reading this blog a little more clarity regarding what cholesterol is, how it is influenced and how it affect our individual health.

First, the standard cholesterol profile does not give us a true picture of what is occurring at a cellular level.  The standard cholesterol panel includes: total cholesterol (all the forms of cholesterol), HDL (the good stuff), LDL-C (the “bad” stuff) and triglycerides.  It is important to recognize that the “-C” in these measurements stands for “a calculation” usually completed by the lab, and not an actual measurement.  Total cholesterol, HDL-C and triglycerides are usually measured and LDL-C is calculated using the Friedewald equation [LDL = total cholesterol – HDL – (triglycerides/5)].  (No, there won’t be a quiz on this at the end  . . . so relax.)

However, an ever increasing body evidence reveals that the concentration and size of the LDL particles correlates much more powerfully to the degree of atherosclerosis progression (arterial blockage) than the calculated LDL concentration or weight (1, 2, 3).

There are three sub-types of LDL that we each need to be aware of: Large “fluffy” LDL particles (type I), medium LDL particles (type II & III), and small dense LDL particles (type IV).

Lipid Planet Image
Weight & Size of VLDL, LDL & HDL

 

Misleading LDL-C
Why LDL-C is misleading: Identical LDL-C of 130 mg/dL can have a low risk (Pattern A) with a few “big fluffy LDL particles or high risk (Pattern B) with many small dense LDL particles.

Second, it is important to realize that HDL and LDL types are actually transport molecules for triglyceride – they are essentially buses for the triglycerides (the passengers).  HDL can be simplistically thought of as taking triglycerides to the fat cells and LDL can be thought of as taking triglycerides from the fat cells to the muscles and other organs for use as fuel.

Third, it is the small dense LDL particles that are more easily oxidized and because of their size, are more likely to cause damage to the lining of the blood vessel leading to damage and blockage.  The large boyant LDL (“big fluffy LDL particles”) contain more Vitamin E and are much less susceptible to oxidation and vascular wall damage.

Lipid Danger Slide

Eating more fat or cholesterol DOES NOT raise small dense LDL particle number.  Eating eggs, bacon and cheese does not raise your cholesterol!  What increases small dense LDL particles then?  It is the presence of higher levels of insulin.  Insulin is increased because of carbohydrate (sugars, starches or fruits) ingestion. It is the bread or the oatmeal you eat with the bacon that is the culprit.  The bread or starch stimulates and insulin response.  Insulin stimulates the production of triglycerides and “calls out more small buses” to transport the increased triglyceride to the fat cells (4, 5, 6, 7).

Fourth, following a very low carbohydrate diet or ketogenic diet has been demonstrated to decreased small dense LDL particle number and correlates with a regression in vascular blockage (8, 9).  So, what does this really mean to you and me?  It means that the low-fat diet dogma that that has been touted from the rooftops and plastered across the cover of every magazine and health journal for the last 50 years is wrong. . . absolutely wrong.

I talk about this and answers questions on today’s Periscope.  You can see the recording on Katch.me with the comments in real time here:

https://www.katch.me/docmuscles/v/2f0b6d07-d56a-368b-b4f6-34a5ab3da916

 

Or, you can watch the video below:

References:

  1. Superko HR, Gadesam RR. Is it LDL particle size or number that correlates with risk for cardiovascular disease? Curr Atheroscler Rep. 2008 Oct;10(5):377-85. PMID: 18706278
  2. Rizzo M, Berneis K. Low-density lipoprotein size and cardiovascular risk assessment. QJM. 2006 Jan;99(1):1-14. PMID: 16371404
  3. Rizzo M, Berneis K, Corrado E, Novo S. The significance of low-density-lipoproteins size in vascular diseases. Int Angiol. 2006 Mar;25(1):4-9. PMID:16520717
  4. Howard BV, Wylie-Rosett J. Sugar and cardiovascular disease: A statement for healthcare professionals from the Committee on Nutrition of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation. 2002 Jul 23;106(4):523-7. PMID: 12135957
  5. Elkeles RS. Blood glucose and coronary heart disease. European Heart Journal (2000) 21, 1735–1737 doi:10.1053/euhj.2000.2331
  6. Stanhope KL, Bremer AA, Medici V, et al. Consumption of Fructose and High Fructose Corn Syrup Increase Postprandial Triglycerides, LDL-Cholesterol, and Apolipoprotein-B in Young Men and Women. The Journal of Clinical Endocrinology and Metabolism. 2011;96(10):E1596-E1605.
  7. Shai I et al. Cirulation. 2010; 121:1200-1208
  8. Krauss RM, et al. Prevalence of LDL subclass pattern B as a function of dietary carbohydrate content for each experimental diet before and after weight loss and stabilization with the diets.  American Journal of Clinical Nutrition. 2006; 83:1025-1031
  9. Gentile M, Panico S, et al., Clinica Chimica Acta, 2013, Association between small dense LDL and early atherosclerosis in a sample of menopausal women, Department of Clinical Medicine and Surgery, University “Federico II” Medical School, Naples, Italy Division of Cardiology, Moscati Hospital, Aversa, Italy A. Cardarelli Hospital, Naples, Italy

PeriScope: How Does Exercise Help Ketosis?

In light of the fact that exercise DOES NOT cause weight loss, exercise has a fascinating ability to enhance ketosis.  No, seriously, I don’t care what your trainer told you, you won’t loose weight with exercise, no mater how hard you try.  However, exercise does help you body attain a ketogenic state.

When you exercise, the muscles take up glucose and oxygen to burn as their primary fuel.  Exercise has actually been shown to enhance this process and reduce the “insulin resistance” effect that the the SAD diet (Standard American Diet) has on 2/3rds of the population (whether they realize it or not).  Mild to moderate exercise like a walk or even a mild jog, and resistance training like weight lifting, yoga or Pilates increased the drive of the glucose into the cells and improves the ability of the cells to use the glucose.

In a person following a carbohydrate restricted diet (Ketogenic, Low-Carb, and even Paleolithic to some degree), the body maintains a stable level of blood sugar by releasing glycogen from the liver and gluconeogenisis as needed to support the 100 grams necessary per day required by the brain (the liver makes about 240 grams per day no mater what you do).  In the absence of extra glucose as fuel, the body will then use triglyceride and/or ketones as fuel.  Exercise improves the sensitivity to the small amount of glucose and actually ramps up the presence of ketones placing the person into a more ketogenic state.

This enhanced ketogensis is often experienced as “second wind” or “being in the zone” or even as an ability to “hyperfocus” during exercise.  But the exercise levels must be in the mild to moderate range for this to be accomplished.

But, there’s a fine balance, if the muscles are pushed too hard to fast, lactic acid builds up because of a shift to an anaerobic state and the acid creates a stress response, triggering cortisol and increased glucose formulation, causing one to shift out of ketosis.

How do you know if you exercising too hard?  You should be exercising hard enough to break a sweat, but not so hard that you can’t carry on a conversation with your partner at the same time.  Over time, as the body becomes more effective at using ketones, you’ll find your exercise intensity can and will improve.

See Dr. Nally try to explain all this while riding his horse Bailey in the White Tank Mountains:

Or you can Katch it here: https://katch.me/docmuscles/v/ce43292a-296f-3de4-bf6f-d19cd688fc62

Have a great weekend!!

The Simple Effects of Ponderizing . . . The First Step in a Principle Based Ketogenic Lifestyle

I have found, over time, that happiness in life seems to be the greatest when I strive for balance in the three basic aspects of life: Mind, Body & Spirit.  Yes, I am a physician, and I spend the majority of my day applying advise and treatment plans that have been demonstrated to be effective through the tried and true scientific method.  However, I know from personal experience, and from working closely with patients for over 15 years, that science alone, does not bring fullness and happiness to life.  Truth and learning can be found through study and also by faith. Finding balance and peace physically is important, but finding that balance emotionally and spiritually are often essential.  Being able to follow a Ketogenic Lifestyle effectively over the long term (longer than 6 months) actually requires understanding of some basic principles.  This is the first in a series of articles regarding The Principle Based Ketogenic Lifestyle.

Ponder LifeI treat patients with obesity, one of the most difficult diseases to address in the medical office.  I find that just applying diet alone doesn’t always solve the problem.  If the patient’s life is out of balance emotionally or spiritually, the stress this causes often halts effective weight loss and metabolic healing.  You may disagree with me on political or religious issues, but healing is not about politics nor is it about religious doctrine – it is about understanding where we are, the path forward, and our potential to get there.  The mind, body and spirit are deeply interconnected.  Often, until we recognize and treat those connections, true healing cannot occur.

The first step in treating any illness, including weight, is recognition of the problem. The Medical Community has recognized Obesity as a disease, but obesity is also a symptom of underlying physical metabolic dysfunction that may be tied to the mind and spirit.  Daily journaling is the tool that lets one see if the dysfunction is tied to mind or spirit.  I ask my patients to keep a daily food journal.  This is very important in looking at the patterns of macro-nutrient intake.   But the more powerful effect of journaling allows one to see how food is tied to emotion – mentally and spiritually.

Simply writing down what you eat each day, when you eat it, and how you felt after you at it is actually quite profound.  The patterns that emerge are usually seen and identified by the patient long before I ever see them.  In fact, patient’s often bring those patterns up before ever showing me their food journals.

I’ve found, in keeping a food journal myself, that combining my journaling with other other daily goals, uplifting thoughts and reminders was even more helpful and powerful.  This can be done on paper, a notebook, a planner or even on the computer.  (I have a few patients who are accountants or engineers – they bring in complex spread sheets).  What is important is daily consistency.  It takes about 3-4 weeks of journaling to begin to see patterns.

I have taken the advise of one of the leaders of my church to “ponderize” a scripture, meaningful poetic verse or truth filled quote each week as part of the journaling process.  He defined “ponderizing” as the act of pondering and memorizing a scripture or a favorite uplifting poem or verse each week.  This is done by writing the verse on a written card or note in a place that you will see it frequently each day during the week.  When you see it, read it and ponder it.  Just the process of frequently reading it will lead to memorization each week.  I have found that reading and pondering a verse 3-4 times a day for a week, lends itself to easy memorization.  Each time you read the verse, think about it and ponder it for a moment, then go on with your day.  This will give you a brief opportunity to elevate your thoughts each day, and will give you a place your mind can go and think when you don’t have to think. It gives your subconscious mind the ability to solve complex patterns at a higher level.

Said David O. McKay, “Tell me what you think about when you don’t have to think, and I’ll tell you what you are.”  “As a man thinketh in his heart, so is he . . . ” (Proverbs 23:7).

PonderingFor some reason, with all the cares of the day, work, family and the challenges of life, I have fallen out of this habit for some time.  When this leader mentioned this process in his comments, I was reminded of the peace and balance I used to feel each week when doing this simple activity.  I have recommitted myself to restart this activity and I invite you to do the same.  This time to ponder opens your mind and allows you access the deeper worries and fears holding you from what you what to accomplish.  It takes great courage to make permanent lifestyle and dietary changes.  When someone can’t clearly see what lies ahead, it fills them with fear, doubt or both.  But journaling, even in its simplest form, gives a person the ability to resist and then master the patterns that have kept them from change.  As Mark Twain said, “Courage is resistance to fear, mastery of fear – not absence of fear.”

Courage is tested when we purse difficult goals, fight against disease with unknown outcomes, or work to regain health.  The testing can be painful.  Journaling, and ponderizing in the process, gives courage to take small steps, one day at a time.   Admitting to, journaling when we fail or make mistakes, fear of failure or feeling unsure actually increases our courage.  Being given a week to ponderize an uplifting scripture or verse enhances that courage .  Journaling successes and failures empowers us individually.  The psychiatrist Carl Jung wrote:

“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 felling himself a man among men.  Here we find a key to the great significance of true unstereotyped 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.'”

Journaling and ponderizing allows one a form of confession and renewal. It gives one courage that you have survived today’s challenges and seen the pattern of fallibility in them.  It is actually energizing.  And, the path to healing begins to become clear.

Journaling also is a great way to outline side effects from carbohydrate withdrawl that will last for 2-4 weeks (That’s for another blog post, however).

Feel free to ask me about the verse that I am ponderizing each week. I will happily tell you which verse I am pondering and memorizing; but, I will in tern, ask you which verse you are ponderizing.

This week, the verse I am ponderizing comes from the Bible – Genesis 35:2-3:

“Then Jacob said unto his household, and to all that were with him, Put away the strange gods that are among you, and be clean, and change your garments: And let us arise, and go up to Beth-el; and I will make there an altar unto God, who answered me in the day of my distress, and was with me in the way which I went.”

Did you begin your food journal?  And, what verse are you going to ponderize this week?

Low-Carb Protein Shake

A number of my patients have asked what I use personally as a protein supplement and whether I use protein shakes.  I’ve struggled to find a great tasting protein shake that does not contain any artificial sweeteners (see my article The Skinny On Sweeteners) that raise the insulin levels.  Most of the pre-prepared shakes (including the Adkins, EAS, Muscle Milk, and many others) will significantly slow weight loss and knock you out of ketosis due to an insulin response stimulated by drinking them.

My sweet wife just perfected our family’s favorite high fat, low carbohydrate protein shake.  Oh, it’s good and  it’s filling.  You’ll love it and you won’t be hungry for at least 3-4 hours after savoring this sweet taste-bud sensation.

This is a great shake for a mid-meal snack or a quick meal on the go.

Dr. Nally’s Low Carb High Fat Protein Shake:

[One serving (~ 2 cups) is 4.5 grams of carbohydrate]

Blend to preferred texture. . . (may add more heavy whipping cream if it is still too thick).
Enjoy!!