Category: Metabolism

March 11, 2018

Long-Term Weight Loss: Why So Many Fail

Over fifty years of data have demonstrated that creating energy deficit through the reduction in caloric intake is effective in reducing weight. . . However, it is only for the short term (1, 2). The biggest challenge physicians face in the treatment of obesity is that calorie restriction fails when it comes to long-term weight loss.

Isn’t Fasting Effective in Long-Term Weight Loss?

With the craze and popularity of intermittent fasting, some have claimed that intermittent fasting is more effective in weight reduction. Recent results demonstrate that this may also be incorrect. In the short term evaluation of caloric restriction and intermittent fasting, reduction in 15-20 lbs of weight is effectively seen and the highly publicized Biggest Loser’s losing ~ 120 lbs. Intermittent fasting and alternate day fasting have been shown to be more effective in lowering insulin levels and other inflammatory markers in the short term.

There is, however, controversy over maintaining weight loss beyond 12 months in the calorie restriction, intermittent and alternate day fasting groups. Forty different studies in a recent literature review, thirty-one of those studies looking at forms of intermittent fasting, demonstrate that the majority of people regain the weight within the first 12 months of attempting to maintain weight loss(3, 5). This is, also, what I have seen for over 18 years of medical practice.

Is Calorie Restriction the Only Way to Lose Fat?

Numerous “experts” claim that the only way to reduce fat is “caloric deficit.” Variations through the use of intermittent, long-term or alternate day fasts can be found all over the internet. In regards to calorie restriction, these “experts” with nothing more than a personal experience and a blog to back their claims preach this louder than the “televangelists” preach religion. Based on the faith that many place in this dogma, it could be a religion. What causes belief in this dogma is that weight and fat loss actually does occur with caloric restriction to a point. The average person will lose 20-25 lbs, however, within 12 months of achieving this goal, most people regain all the weight. (No one ever mentions the almost universal problem with long-term weight loss, especially those “experts.”)

Prolonged calorie restricted fasts, intermittent fasts, and alternate day fasts are often grouped together into the fasting approach, causing significant confusion among those that I speak to and counsel in my office. There is great data that alternate day fasts do not have the reduction in resting energy expenditure that prolonged fasting, intermittent fasting and calorie restriction cause. However, none of these approaches appears to solve the problem of weight re-gain after long-term (12-24 months into maintenance) weight loss (3). And, a recent study of 100 men participating in alternate day fasting showed that there was a 38% dropout rate, implying that without close supervision and direction, maintenance of this lifestyle is not feasible for over 1/3rd of those attempting it.

Long-Term Weight Loss Failure Brings Tears

Failure on calorie restricted diets, low fat diets, and intermittent fasting diets with weight regain at twelve to twenty-four months is the most common reason people end up in my office in tears. They’ve fasted, starved themselves, calorie restricted, tried every form of exercise, and still regained the weight. Trainers, coaches and “experts” have belittled them for “cheating” or just not keeping to the diet. Yet, we know that calorie restriction and intermittent fasting cause a rebound in leptin, amilyn, peptid YY, cholecystikinin, insulin, ghrelin, gastric inhibitory peptide and pancreatic poly peptide by twelve months causing ineffective long-term weight loss (6). The dramatic rise in these hormones stimulates tremendous hunger, especially from ghrelin and leptin.

N Eng J Med 27 Oct 2011. Mean (±SE) Fasting and Postprandial Levels of Ghrelin, Peptide YY, Amylin, and Cholecystokinin (CCK) at Baseline, 10 Weeks, and 62 Weeks.

Although less problematic in alternate day fasting, these calorie restricted approaches also cause dramatic slowing of the metabolism at the twelve month mark. In many cases, the metabolic rate never actually returns to baseline, creating even more difficulty in losing further weight or even maintaining weight (6).

N Engl J Med 27 Oct 2011. Mean changes is weight from 0 – 62 weeks.

Is Gastric Bypass or Gastric Sleeve the Solution?

Gastric bypass and the gastric sleeve procedures have been touted as the solution to this problem, as they decrease ghrelin, however, 5-10 years later, these patients are also back in my office. They find that 5-10 years after these procedures the weight returns, cholesterol and blood pressure rise, and diabetes returns. These hormones kick into high gear, stimulating hunger in the face of a slowed metabolism, that to date, has been the driver for weight regain in the majority of people. People find it nearly impossible to overcome the hunger. You may have experienced this, I know I have.

It’s the Hormones, Baby!

So, what is the answer? It’s the hormones. (WARNING – You’ll hear that when your wife is pregnant, too, gentlemen). We are hormonal beings, both in weight gain, and in pregnancy. Trying to preach calorie control to a hormonal being is like showing up at the brothel to baptize the staff. You might get them into the water, but you’re probably not getting them returning weekly to church or pay a tithe.

So, how do you manipulate the hormones in a way to control the rebounding hunger and suppression of metabolism? This is where we put a bit of twist on the knowledge we’ve gained from alternate day fasting. Recent research shows that “mild” energy deficit in a pulsatile manner, that has the ability to mimicking the body’s normal bio-rhythm’s is dramatically effective in reducing weight and maintaining normal hormonal function without cause of rebound metabolic slowing (4).

Pulsed Mild Energy Restriction

What does this mean in layman’s terms? It means that if we provide a diet that maintains satiety hormones while providing a period of baseline total energy expenditure needs and a period of mildly reduce caloric intake in a pulsed or cyclic manner, greater weight loss occurs and there is no rebound of weight 1-2 years later.

The main reason I’ve not jumped on the intermittent fasting band wagon is the shift in leptin, amylin, ghrelin and GLP-1 signaling that regularly occurs at the 6-12 month mark. The rebound of these hormones causes weight re-gain and is what prevents successful long-term weight loss. A number of people come to my office and tell me they couldn’t follow a ketogenic diet, so they’re doing intermittent fasting and it works . . . for a while. Then, they end up in my office having hit a plateau or fallen off the wagon and regained all the weight. They are completely confused and don’t understand what happned. Most of them are convinced it’s their thyroid or cortisol and they’ve seen every naturopath and functional medicine doctor in town.

What people really need is a simple approach to long-term weight loss without having to spend the night in the physiology lab every two weeks sleeping under a ventilated hood system.

The Ketogenic Lifestyle is a Pulsed Energy Lifestyle

First, it is essential to turn off the insulin load. Insulin is the master hormone. This is done by a ketogenic lifestyle that restricts carbohydrates.
Second, providing adequate protein to supply maintenance of muscle and testosterone is key.
Third, providing adequate fat is the simple way to maintain leptin, ghrelin, amylin, GLP-1 (among the others) and long-term weight loss. Can you eat too much fat? Of course you can. But, because each of us have differing levels of stress and activity each day, this fat intake becomes the lever for hunger control.
Fourth, the use of exogenous ketones ensures easily accessible ketone (short chain fatty acids) to modulate adipose (white fat) signaling of the liver without large caloric intake through the portal vein by first pass of liver metabolism. The ketones also help stabilize the gut bacteria. The combination of hormone balance between the liver and fat cells and improvement of gut bacteria suppresses key hunger hormones and aids glucose regulation between the fatty tissues and the liver. Ketones, both endogenous and exogenous, suppress production of TNF-alpha, IL-6, resistin, and stabilize production of adiponectin and leptin from the adipose cells (7, 8, 9).

In my office, once we calculate the basic protein needs daily, we start with a 1:1 ratio of protein to fat. Then, the fat is adjusted up or down based on hunger. Remember, hunger occurs, because your body produces hormones. The addition of fat to a diet that is not stimulating large amounts of insulin resets the hormone patterns back to normal without causing weight gain.

Give Obese People Fat Ad Libitum?

“Sure, Dr. Nally, but what about those people who don’t know if they are hungry, bored, stressed or just have a bacon fixation? You can’t just give them all the fat they want?!”

Why not? Implying that people aren’t smart enough to know when they are full is a bit of a fascist philosophy, don’t you think?

Do people over eat? Sure they do. But, I’ve found that when you give people an antidote to hunger (using fat intake in the presence of stabilized insulin levels) over a few months, people begin to recognize true hunger from other forms of cravings. This is especially true when they keep a diet journal. This gives people the ability to begin listening to their own bodies, responding accordingly and governing their stress, eating, exercise and activity. Keeping a diet journal is key to long-term weight loss. And, isn’t helping people use their own agency to improve their health really what we’re trying to do?

Interestingly, doing this over the years seems to line up with the findings of this year’s MATADOR study in the International Journal of Obesity. They found that mild intermittent energy restriction of about 30-33% for two weeks, then interrupting this with two weeks of a diet that was energy balanced for needs improved both short and long-term weight loss efficiency (4). In looking at my, and my patient’s diet journals, this energy restriction of about 1/3 of needed calories cyclically seems to happens naturally with a ketogenic lifestyle, without even counting calories. (Calories are a swear-word in my office).

What does the correct long-term wight loss program look like in a diet or meal plan? Well, you’ll have to join the Ketogenic Lifestyle 101 Course to see what that really means to you individually. I look forward to seeing you there.

Want to find out more about the Ketogenic Lifestyle 101 course? CLICK HERE.

Have you read my book The Keto Cure? Get a signed copy from me by clicking HERE.

References:

Bronson FH, Marsteller FA. “Effect of short-term food deprivation on reproduction in female mice.” Biol Reprod. Oct 1985; 33(3): 660-7. https://www.ncbi.nlm.nih.gov/pubmed/4052528?dopt=Abstract&holding=npg
Connors JM, DeVito WJ, Hedge GA. “Effects of food deprivation on the feedback regulation of the hypothalamic-pituitary-thyroid axis of the rat.” Endocrinology. Sep 1985. 117(3): 900-6. https://www.ncbi.nlm.nih.gov/pubmed/3926471?dopt=Abstract&holding=npg
Seimon RV, Roekenes JA, Zibellini J, Zhu B, Gibson AA, Hills AP, Wood RE, King NA, Byrne NM, Sainsbury A. “Do intermittent diets provide physiological beneftis over continuous diets for weight loss? A systematic review of clinical trials.” Mol Cell Endo. 15 Dec 2015. 418(2): 153-172. https://www.sciencedirect.com/science/article/pii/S0303720715300800
Byrne NM, Sainsbury A, King NA, Hills AP, Wood RE. “Intermittent energy restriction improves weight loss efficiency in obese men: the MATADOR study.” Int J Obes. 2018. 42:129-138. https://www.nature.com/articles/ijo2017206
Trepanowski JF, Kroeger CM, Barnosky A. “Effect of Alternate-Day Fasting on Weight Loss, Weight Maintenance, and Cardioprotection Among Metabolically Healthy Obese Adults.” JAMA Intern Med. Jul 2017. 177(7): 930-938. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2623528?redirect=true
Sumithran P, Prendergast LA, Delbridge E, Purcell K, Shulkes A, Kriketos A, Proietto J. “Long-term persistence of hormonal adaptations to weight loss.” N Engl J Med. 27 Oct 2011. 365: 1597-1604. http://www.nejm.org/doi/full/10.1056/NEJMoa1105816
Asrih M et al., “Ketogenic diet impairs FGF21 signaling and promotes differential inflammatory responses in the liver and white adipose tissue.” PlosOne. 14 May 2015. Open Access. https://doi.org/10.1371/journal.pone.0126364
Veniant MM et al. “FGF21 promotes metabolic homeostasis via white adipose and leptin in mice.” PlosOne. Jul 2012. Open access. https://doi.org/10.1371/journal.pone.0040164
Whittle AJ, “FGF21 conducts a metabolic orchestra and fat is a key player.” Endocrinology. 1 May 2016. 157(5): 1722-1724.

February 3, 2016

Ketogenic Lifestyle Rule #3: Be BOLD or Be Italic, but never be Regular: Why Size Matters with Cholesterol

On this evenings PeriScope video we talked about cholesterol. And, and you can see an updated, in depth discussion about cholesterol on my YouTube channel here. Please go check it out and if you find it helpful, please follow me here and on YouTube. The is the burning question on everyone’s mind who starts a Low-Carb, High Fat or Ketogenic Diet: “What will happen to my cholesterol if I lower my carbohydrates and eat more fat?”

The answer . . . it will improve!

How do I know this? I’m an obesity specialist. I specialize in FAT or lipids (to put it kinder scientific terms). To specialize in fat, one must know where it came from, what it’s made of and where it is going. And, this has been the case with every single patient I have used this dietary change with for the last ten years, myself included.

Lets start with the contents of the standard cholesterol or “Lipid Panel”:

Total Cholesterol
HDL-C (the calculated number for “good” cholesterol)
LDL-C (the calculated number for “bad” cholesterol).
Triglycerides

The first problem with this panel is that it makes you believe that there are four different forms of cholesterol. NOT TRUE! Actually cholesterol is cholesterol, but it comes in different sizes based on what it’s function is at that moment in time. Think of cholesterol as a bus. There are bigger busses and smaller busses. Second, triglyceride is actually the passenger inside the HDL and the LDL busses. And third, Total Cholesterol is the sum of the HDL, LDL, as well as ILDL & VLDL which aren’t reported in the “Lipid Panel” above.

The fourth thing that this panel doesn’t tell you is that HDL & LDL are actually made up of sub-types or sub-particles and are further differentiated by weight and size.

For our conversation, we need to know that the number of LDL particles (LDL-P) can actually be measured in four different ways and these measurements have identifed that there are three sub-types: “Big fluffy” large dense LDL, medium dense LDL, and small-dense LDL. Research has identified that increased numbers of small-dense LDL correlates closely with risk for inflammation, heart disease and vascular disease (1).

If you’ve been a follower of my blog for a while, you’ve seen this picture before. This picture illustrates why an LDL-C (the bad cholesterol measurement) can be misleading. Both sides of the scale reflect an LDL-C of 130 mg./dl. However, the LEFT side is made up of only a few large fluffy LDL particles (this is the person with reduced risk for heart disease) called Pattern A or a LDL healthy cholesterol level. Even though the LDL-C is elevate above the recommended level of 100 mg/dl, the patient on the left has much less risk for vascular disease (this is why you CAN’T trust LDL-C as a risk factor).

The RIGHT side of the scale shows that the same 130 mg/dl of LDL-C is made up of man more small dense LDL particles (called “sd LDL-P”) with a Pattern B type that is as increased risk for heart or vascular disease. This is where the standard Lipid Panel above, fails to identify heart disease and it’s progression.

Research tells us that the small dense LDL particle levels increase as the triglycerides increase. And we know that Triglyceride levels increase in the presence of higher levels of insulin leading to a cascade of inflammatory changes. Insulin is directly increased by the ingestion of simple and complex carbohydrates. Insulin also increases with the ingestion of too much protein. So, that chicken salad or the oatmeal you ate, thinking it was good for you, actually just raised your cholesterol. If you are insulin resistant, your cholesterol just increased by 2-10 times the normal level (see my article here on how insulin resistance causes this.)

“Ok, but Dr. Nally, there are four different companies out in the market measuring these fractional forms of cholesterol. Which one should I choose?”

There are actually five different ways you can check your risk.

Apolipoprotein levels. This can be done through most labs; however, this test doesn’t give you additional information on insulin resistance that the other tests can.
Berkley Heart Lab’s Gradient Gel Electrophoresis – This test gives a differentiation based on particle estimation between Pattern A and Pattern B
Vertical Auto Profile (VAP-II) test by Arthrotec – This test determines predominant LDL size but does not give a quantifiable lipoprotein particle number which I find very useful in monitoring progression of insulin resistance and inflammation.
NMR Spectroscopy from LipoScience – This test measures actual lipoprotein particle number as well as insulin resistance scores and will add the Lp(a) if requested. I find the NMR to be the most user friendly test and useful clinically in monitoring cholesterol, vascular risk, insulin resistance progression and control of the inflammation caused by diabetes. This test has the least variation based on collection methods if frozen storage is used.
Ion-Mobility from Quest – This test also measures lipoprotein particle number but does not include insulin resistance risk or scoring. Because the test is done through a gas-phase electric differential, the reference ranges for normal are slightly different from the NMR.

In regards to screening for cardiovascular risk, the use of all five approaches are more effective than the standard lipid panel. However, I have found that clinically the NMR Lipo-profile or the Cardio I-Q Ion-Mobility tests are the most useful in additionally monitoring insulin resistance, inflammation, and disease progression.

It is was the use of these tests that demonstrated to me the profound effect of carbohydrate restriction and ketogenic lifestyles on vascular and metabolic risk. We talk more about these tests on my YouTube video .

Hope this helps.

References:

Williams PT, et al. Comparison of four methods of analysis of lipoprotein particle subfractions for their association with angiographic progression of coronary artery disease. Atherosclerosis. 2014 April; 233(2): 713-720.

December 22, 2015

Why the Calorie is NOT King

Today in the office I had the calorie conversation again . . . three times. We have an entire society with a very influential health and fitness industry built around the almighty calorie. Has it helped? Looking at our 5 year obesity outcomes. It hasn’t helped a bit. In fact, it is worse. In 1985 only 19% of U.S. adults were obese.

U.S. Obesity Adult 2011

U.S. Adult Obesity 2014

In 2014, 34.5% of U.S. adults were obese. The numbers this year are approaching 35.6% You can see the dramatic increase in obesity by 1-3% every year for the last 5 years in the CDC images above.

For over 50 years we have been told that caloric restriction and fat restriction is the solution. But by the numbers above, the 58 million people in the U.S. utilize a gym or health club to burn off those calories aren’t seeing the success that they should be expecting.

Why? Because the calorie is NOT king. What do I mean by that? We don’t gain weight because of the thermogenic dogma we’ve been taught for the last 50 years. Our weight gain is driven by a hormone response to food. Hear more about why the calorie is NOT king on tonight’s PeriScope. You can Katch it here with all the live stream comments and hearts at Katch.me/docmuscles.

Or you can watch the video without the comments here:

December 13, 2015

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.

After 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 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.

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?

Normal Spider (9)

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:

November 28, 2015

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.

I’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 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.

If 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.That 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

Fifth 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 20% 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.

November 24, 2015

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.

November 20, 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.

November 12, 2015

How Your Fruit and Your Alcohol Stop Your Weight Loss

Yes, your fruit makes you fat just like your beer gives you a beer belly. . .

It is fascinating how similarly fructose (the sugar in fruit) and alcohol are processed through the liver. Both of them increase insulin and both increase triglyceride production as a byproduct of their metabolism. This is clearly pointed out in Robert Lustig’s paper published in the Journal of the American Dietetic Association in 2010.

The metabolic pathways are very clearly outlined below:

You can Katch my PeriScope conversation about this below or with the comments and hearts included at Katch.me/docmuscles.