Home » Carbohydrate Restriction

Tag: Carbohydrate Restriction

Long-term weight loss

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.

Hormones after weight loss
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).

Weight rebound after loss
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.

Respect My HormonesSo, 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:

  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. Whittle AJ, “FGF21 conducts a metabolic orchestra and fat is a key player.” Endocrinology. 1 May 2016. 157(5): 1722-1724.
Fat Lock Box #DocMuscles #KetonianKing

Ketones – One of the Keys to the Fat Lock-Box

Do you have the keys to your “fat lock-box?”

Lock-boxes have always fascinated me.  Lock-boxes with special keys are even more fascinating.  The more I’ve learned about fat cells (adipocytes), the more I think about them as special fuel depositories or fat lock-boxes.  Before the invention of refrigerators, fast-food, Bisquick and beer, our bodies preserved and reserved fat as a precious commodity.

The body, when given fat with carbohydrates or excess protein, quickly places the fat into a lock-box for safe keeping.  It does this for two reasons. First, the body can store fat very efficiently. Second, hormone signals stimulate fat storage when other fuel sources (carbohydrate & protein) are present in excess. The body can access this stored fuel only when the right presentation of hormonal keys are present.  Fascinatingly, we now know from recent research, there are actually three types of lock-boxes for fat in the human body (white adipose tissue, brown adipose tissue, and tan adipose tissue).

The greatest challenge for the obesity doctor is getting into the fat lock-box.  Some people’s boxes are like the “Jack-in-the-Box” you had as a child – just add a little exercise spinning the handle and the box pops open (These are those people that say, “Oh, just eat less and exercise and you’ll lose weight.”)  For the majority of the people I see, it’s more like the lock above with a four or five part key required to turn the gears just right.  (And, that key often only seems available on a quarter moon at midnight when the temperature is 72 degrees.)  Fat cells, called adipocytes, require four, and possibly more, keys to open them up and access the fuel inside.  Exercise is only one of those keys.  However, exercise alone often fails.

Over the last 18 months, I have been surprisingly impressed with the results patients have by the addition of both medium chain triglycerides and exogenous ketones.   A number of people have asked me, “Why do you encourage the addition of exogenous ketones to a person already following a ketogenic diet?”

Others just accuse me of self promotion, saying, “You’re just trying to sell a product!”

Or they exclaim, “Giving more ketones is just a waste of time and money.”

A few of the uneducated holler from across cyberspace, “You’re just going to cause ketoacidosis!”

Believe me, I’ve heard it all.  And, the skepticism is understandable.  I work with people every day, looking closely at weight gain/loss, metabolism, cholesterol, blood pressure, inflammation, etc.  With any “low-carb” or “ketogenic product,” I test it out on myself and my family, before I offer it to my patients or even consider encouraging its use in my practice.  I have this desire to understand “the how” and “the why” before I prescribe the who and when.

The Fat Lock-Box Keys

First , let’s talk about the adipocyte as a fat lock-box – and where you find the keys. Then, we’ll discuss how products may or may not help.

Insulin

There is only one door INTO the adipocyte for the fat, and the key to that door is insulin.   Insulin stimulates an enzyme called lipoprotein lipase that essentially pulls the fat from the cholesterol molecule into the fat cell.  Without insulin, fat doesn’t enter the fat cell.  As a result, type I diabetics (those that make absolutely no insulin) look anorexic if they don’t take their needed insulin.   Insulin is also the first key to the back door on the adipocyte.  Actually, if there is too much insulin in the system, fat enters easily through the front door but cannot exit the back door (Picture 1). Insulin seals up the back door so that fat cannot exit very effectively.

That’s why insulin is the master hormone when it comes to obesity.  You’ve got to lower the over-all insulin load to get the adipocyte slowing fat entry and increasing fat exit.  If you don’t do that, I don’t care how much you exercise, 85% of the population will struggle with weight loss.  Hmmm, seems kind a familiar to the last 50 years of our obesity epidemic, No?

Stimulation Lipolysis #DocMuscles #KetonianKing
Picture 1 – Four Key Pathways to Adipocyte Stimulation of Lipolysis

Catecholamines

The second key to the back door of the fat cells are the catecholamines.  These are adrenaline (epinephrine), norepinephrine, adrenocorticotropic hormone (ACTH) and even serotonin.  These hormones are produced in the adrenal glands through exercise, fear and even recollection of powerful memories. Medications can also stimulate production of these hormones.  The catecholamines stimulate cAMP.  cAMP opens the fat cell, releasing fatty acids for fuel.

#WhereIsBaconBoy #DocMuscles #KetonianKing

The thyroid hormone conversion of T4 to T3 also plays a role in uptake of the catecholamines by adnylyl cyclase (AC).  Low levels of T3 (like those seen in hypothyroidism or in cases of thyroiditis) also inhibit unlocking of the fat lock-box.  Conversion of T4 to T3 is driven by the presence of bile salts in the gut.  Increase fat intake increases the presence of the bile salts which naturally leads to better T3 conversion.  Hence my constant references to eating more fat and bacon. .

Inflammation & Medications

The third key is an inhibitory effect on adenylyl cyclase (AC) activity by alpha and beta adrenoreceptors, adenosine, prostaglandins, neuropeptide Y, peptide YY, HM74-R & nicotinic acid.  These inhibitory and inflammatory hormones produced in the brain, gut and other areas decrease cAMP activity in the fat cell and slow fat loss.  The fancy long names are all hormones causing inflammation.  Of note, many are also stimulated by medications including blood pressure lowering drugs. Check with your doctor if the medications you are taking may be causing weight gain, or halting your weight loss.

Please note that the first three keys have effect on the cAMP pathway for release of fat from the adipocyte.  These three keys turn on or off effective function of cAMP leading release of fatty acids from the fat cell.

Naturitic Peptides

The fourth key follows a separate pathway.  This is why I’ve clinically seen patients experience weight loss even in the presence of higher insulin, inflammatory disease or hypothyroidism. This key activates release of the naturitic peptides (ANP, BNP).  These hormones are released from the heart when it squeezes more powerfully.  As the cardiac muscle contracts, it releases ANP & BNP hormones.  These hormones stimulate the cGMP pathway in the adipocyte.   It then activates hormone sensitive lipase (HSL) and perilipin to release free fatty acids.  Again, this pathway is separate from the pathway by which the first three keys released fat.   Exercise increases heart contractility, but is inhibited by high insulin levels.  However, ketones themselves also stimulate this increased contractile effect.

Hypothalamus-Pituitary-Gonadal (HPG) Axis & Testosterone

There actually is a fifth key not referenced above.  The fifth key to the fat lock-box amplifies testosterone’s presence through the HPG axis.  Insulin resistance and leptin resistance lower testosterone in men and raise it in women, causing poly-cystic ovarian syndrome (PCOS).   Normalizing insulin levels (with a ketogenic diet) while at the same time increasing ketones as the primary fuel powerfully resets the HPG axis through a complex series of hormonal reactions.  Growth hormone is balanced and testosterone returns to a normal range.

Clinically, 60% of the people I see in the office have abnormal testosterone due to insulin resistance. This leads to hypogonadism in men and PCOS (abnormal periods, facial hair growth and/or infertility) in women.  Restricting carbohydrates and maintaining nutritional ketosis by diet and/or addition of exogenous ketones has a powerful corrective factor in these people.

Testosterone influences the up-regulation of the alpha & beta adrenergic receptors (the 2nd & 3rd key above).  Hence, if your testosterone is low, it has a suppression on the way that the catecholamines influence fatty acid release from the fat cells.  If your testosterone and growth hormone are normal, muscle development and adrenaline stimulus from exercise helps amplify the use and mobilization of fat from the fat cell.  In people with insulin resistance and leptin resistance, exercise and the catecholamines don’t have the same fat burning effect.

What Does This Actually Mean?

Yes, I have greatly simplified a series of very complex hormonal pathways in the explanation of the keys above.  Why do you think understanding obesity has been so difficult?  Think of your adipocytes as a fat lock-box.

What’s even more important is the knowledge that the fat cell DOES NOT open or close because of calories.  There is no dogmatic calorie-meter on the wall of the fat cell.  There is no calorie key to the fat lock-box.  Really, . . . in the 50 years of studying fat, researchers haven’t found one.  (Prove me wrong when you show me an electron micro-graph of a calorie-meter in the wall of a cell).  Science has demonstrated multiple times that the lack of food from starvation or excessive fasting suppresses thyroid function (an inhibitory effect on key #3).  Restricting calories actually inhibits fat loss in many people.

The fat lock-box keys I refer to above are hormone responses to the presence of macro-nutrients (food).  That means, first reduce your carbohydrate intake by eating real food from good sources. You can learn how to get started by registering for my FREE six part weight loss mini-course.  Second, be as active as you can. Third, reduce stress and medications that have inhibitory effect on catacholamines. Fourth, balance your thyroid. And, fifth, get into ketosis and consider adding exogenous ketones to your dietary regimen.  It really is that simple.

References

(For those of you that still believe there is a calorie key – or just need something to do while in the bathroom):

  1. Lafontan et al. Arterioscler Thromb Vasc Biol. 2005
  2. Lenard NR, Obesity, 2008
  3. Li XF et al, Endo (April 2004) Vol 145
  4. Liu YY& Brent GA, Trends Endocrinol Metab. 2010 Mar; 21(3): 166–173
  5. Max Lafontan et al. Arterioscler Thromb Vasc Biol. 2005;25:2032-2042
  6. Skorupskaite K et al, Hum Rep Update, Mar 2014, vol 20

You're Doing It Wrong: Can 50 Years of Nutritional Advise Really be that Wrong?

Listen in as Dr. Nally discusses how we got to be the fattest and sickest country in the world after 50-60 years of bad science influenced by the media and politics.  How can a ketogenic diet help the diseases of civilization?  Listen in and then click the link in the menu above to get my six-part mini course instruction.

We also discuss Dr Nally’s daily diet and his use of exogenous ketones.

Podcast #32: Hereditary Angioedema, Lower Blood Ketones, Statins, Healthy Keto Lifestyle

Hereditary AngioEdema.jpg
Stomach Pain & Swelling with Hereditary Angio-Edema (HAE)

Listen to KetoTalk Podcast #32 where we talk about hereditary angio-edema, adequate ketone ranges, statin use while in ketosis and healthy keto questions.  You can listen in by going to KetoTalk.com or you can listen in on iTunes.

Statin.jpg

“About 40 percent of my older patient population who take statins while eating ketogenic experience some form of myalgia they didn’t have before. And there’s an amplified side effect profile: muscle ache, joint pain, generalized fatigue, liver enzyme elevation, and cloudy headed.” — Dr. Adam Nally

 

Pizza & Family Gatherings, Is A Carb A Carb, Cataracts, & Hyperinsulinemia On Keto

Giant Pizza Slice

LISTEN AND DOWNLOAD AT ITUNES

LISTEN ON YOUR COMPUTER AT KETOTALK.COM

If 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 the blogosphere, and our two amazing co-hosts are shooting them down one at a time. Keto Talk is co-hosted by 10-year veteran health podcaster and international bestselling author Jimmy Moore from “Livin’ La Vida Low-Carb” and Arizona osteopath and certified obesity medicine physician Dr. Adam Nally from “Doc Muscles” who thoroughly share from their wealth of experience on the ketogenic lifestyle each and every Thursday.

KetoTalk: Episode 27 -Mailbox Blitz, Low Energy, Headache, Stomach-Ache, Breast-Feeding While On Keto

Mailbox desert

Listen in today as Jimmy and Adam blaze through a bunch of listener questions in Episode 27 of KetoTalk with Jimmy and the Doc!

GetAdaptBars

KEY QUOTE: “Children are born in ketosis, so ketones are perfect for babies. The level of fat in breast-milk is essential for them to maintain their health and their growth.” — Dr. Adam Nally

Here’s are the 12 questions Jimmy and Adam answered in this special Keto Talk Mailbox Blitz extended podcast today:

– Testimonial from someone who learned his lesson why it’s important to stay ketogenic all the time
– Three-decade study confirms saturated fats are bad for health
– Is increased testosterone from a ketogenic diet a bad thing for women?
– Why am I still struggling with low energy and low ketones after months of being in ketosis?
– Can being in nutritional ketosis above 1.0 mmol cause painful headaches?
– Do artificial sweeteners and stevia raise insulin?
– Is my ketogenic diet causing me to cramp up before and during my half marathon racing?
– Is MCT oil a better fat to use on a ketogenic diet than other fats like coconut oil, cream, or butter?
– Why do I have a constant stomachache while I’m on a ketogenic diet?
– Do you have to be in ketosis to burn fat?
– Does being in ketosis lead to daily spotting and extended periods?
– Are ketones in my baby’s breastmilk safe for her to consume? And why did my milk supply drop when I went keto?
– What is the impact of the supplement creatine on ketones, blood sugar, and insulin levels?
– Can I ease into ketosis as a way to avoid the dreaded “keto flu?”

KEY QUOTE: “If you’re not feeling energy after that adaptation period of 2-4 weeks at the very most, then you’re doing something wrong. Let that be your wakeup call to change something.” — Jimmy Moore

KetonesKETOOS

Listen in here at KetoTalk.com or you can download the episode for free on iTunes.

How Fat Lowers Your Blood Pressure

Hypertension (elevated blood pressure) is one of the triad symptoms of metabolic syndrome.  Most of the hypertension that I see clinically is driven by insulin resistance as Blood Pressure Surprisethe underlying cause.  I see this problem in a very large majority of the people in my office and I am seeing people younger and younger show up with continually increasing blood pressure.
In medical school, we were taught to treat “borderline” or “slightly elevated blood pressure,” through “lifestyle changes” which was another way of saying exercise, caloric restriction  & hold the salt.  But most physicians today will tell you that exercise, salt & caloric restriction doesn’t work.  When asked why the 34 year old male in my office suddenly has elevated blood pressure, the only explanation we had was it is a “genetic problem,” or “blood pressure naturally goes up as we get older,” or “you’ve been eating too much salt,” and they are started on blood pressure medication and sent on their way. But, as time went on, I found that I had to keep adding more and more blood pressure medication to control the continually rising blood pressure of the patients in my practice.

Most of these people will have a progressive elevation in blood pressure over time, and these blood pressure (anti-hypertensive) medications are/were continually raised until the person is on four or five different blood pressure pills at maximal doses.  Again, when questioned why, their genetics are blamed and that is the end of it.  Or is it?!Time Changes Everything

What shocked me was that when I took patients off of salt & caloric restriction, and placed them on low carbohydrate high fat diets (and yes, I gave them back their salt), their blood pressure normalized. I noticed that as their fasting insulin levels began to fall, their blood pressure began to return to normal.

What?!  Blood pressure rise is caused by insulin?!

Ummm . . . Yes!

I am a prime example.  During the first few years of my medical practice and reserve military service, we had routine vitals checkups. I was working out 3-5 days a week with weights and running 3-5 miles 2-3 times a week and restricting my calories to 1500 per day.  So, I thought I was in pretty good shape.  However, it was not uncommon for for the nurse to raise her eyebrows at my blood pressure readings in the 140-160 systolic and 85-98 range diastolic.  “Oh, it’s the lack of sleep last night,” or “it’s the caffeine I had this morning,” would be my excuse.  But I was making a lot of excuses, and in light of those excuses, my caloric restriction, exercise and salt restriction, I was also still gaining weight.

Nally 1998 Expanding Waist

 

By the 5th year of my medical practice, I weighed 60 lbs heavier than I do today and I struggled to keep my blood pressure under 150/95.  I was violating my own counsel . . . don’t trust a fat doctor for nutritional advise. (Or, was that advise from Dr.House?)

Nally 2016
A much slimmer, healthier and happier Dr. Nally (center) in 2016

After cutting out the carbohydrates (I’ve kept my carbohydrate intake < 20 grams per day), moderating my protein intake and eating all the fat I am hungry for each day, my recent physical examination at the beginning of June 2016 revealed my blood pressure at 112/64.  I don’t remember ever having blood pressure that low. And to be honest, I didn’t sleep well the night before my exam due to a number of middle of the night patient calls.

Loegolas Blood Pressure

When I first started treating the insulin resistance problem in the human, rather than the blood pressure problem, I began to see immediate reductions in blood pressure within one to two weeks.  So much of a reduction that if I didn’t warn the patient that they should Himalayan Saltbegin to back down their blood pressure medications, they would experience symptoms of dizziness, light-headedness, headache and a few patient’s nearly passing out.   On a low-carbohydrate, high-fat (ketogenic) diet you need salt (sodium, potassium, & magnesium).
The process of burning fat as fuel causes you to lose increased amounts of sodium & potassium, and you have to replace these electrolytes.  A number of my patients begin a low-carbohydrate, high-fat diet and are afraid of increasing their salt intake.  Not replacing these electrolytes while on a ketogenic diet can also lead to low blood pressure, dehydrate and dizziness.

 

I often wondered why applying a ketogenic diet had such a profound effect on blood pressure so quickly.  Dr. Robert Lustig helped answer that question for me.

In order to understand how the Standard American Diet (we call it the SAD diet in my office) raises your blood pressure, it is important to understand how the body processes the basic sugar molecule.  Sugar is one glucose molecule bound to a fructose molecule.  This is broken down in the body and 20% of the glucose is metabolized in the liver, the other 80% is sent on to be used as fuel throughout the body. Fructose, however, is where the problems arise.  100% of the fructose is metabolized in the liver, and the by product of fructose metabolism is increasing the liver’s production of MORE glucose and the byproduct of uric acid. Uric acid is produced and this inhibits the production of nitric oxide. The diminished nitric oxide in the presence of an increased level of glucose (stimulating increased insulin production due to eating starches) constricts the blood vessels and raises blood pressure.   Yes, that donut you just ate raised your blood pressure for the next 12 hours. GetAdaptBars

The mechanism that fructose containing carbohydrates, sugars and starches raise blood pressure, cholesterol and cause weight gain can be seen in the really complex diagram found in Dr. Lustig’s 2010 article:

Metabolism of Fructose

 

So, how do you lower your blood pressure through diet?

First, cut out all the simple sugars. These include anything with table sugar, high fructose corn syrup and corn syrup.  (This is why people with any change in diet see some improvement in weight and blood pressure as they remove the simple sugars like candy, sugared drinks and pastries from their diet.)

Second, limit your overall intake of other sources of carbohydrates including any type of bread, rice, pasta, tortilla, potato, corn and carrots.  Realize that carbohydrate in fruit is fructose, and when taken with other forms of glucose can have the same effect as table sugar – it can and will raise your blood pressure, as well as halt or cause weight gain.

Third, if you are taking blood pressure medications for hypertension, see your doctor about close monitoring of your blood pressure as it can and will drop within 2-4 weeks of making these dietary changes.

Maintaining ketosis is really important for weight loss and blood pressure or hypertension control. I am very much an advocate of using real food for this process, but I have also found that the use of exogenous ketone salts aid significantly in maintaining ketosis.  I have found that exogenous ketones are the next step in bridging the difficulty of day to day maintenance of ketosis.

It isn’t making the mistakes that’s critical; it’s correcting them and getting on with the task that’s important.  If you’ve been calorie restricting and exercising to lower you blood pressure, don’t fret.  A simple change in your diet focused on restricting starches and carbohydrates has been demonstrated in my office to be more powerful than many of the blood pressure medications we’ve used for years.

Learn how to get started on a low carbohydrate, high fat (ketogenic) diet here.  You can also read about the basic principles in my recent articles  The Principle Based Ketogenic Lifestyle – Part I and Ketogenic Principles – Part II.

Ketogenic Diet Halts Tumor Growth

 

Prostate Cancer Cell Replication
Prostate Cancer Cell Replication

It has long been understood that tumor cells of any kind require high levels of glucose to grow and spread (1,2).  It is also recognized that higher levels of insulin, commonly found in patients with insulin resistance or type II diabetes, are 2.4 times more likely to stimulate the development of breast cancer (3). A diet low in glucose has thereby been theorized to be an adjunct to cancer treatment.

Ketogenic diets have been demonstrated to be therapeutically useful in the treatments of epilepsy and cardiovascular disease (4). A ketogenic diet is one in which carbohydrate levels are kept below 50 grams per day and fat intake is increased to the point that the body shifts its metabolism to use triglycerides, and the ketones derived from triglycerides, as the primary fuel source for the majority of the cells within the body.  With this understanding in mind, the application of a ketogenic diet, one high in fat and protein with limited carbohydrate or glucose has been suggested as a adjunct to cancer treatments (5).

KetoOS
KetoOS – Drinkable Exogenous Ketones

A recent study (6) in the Oncology Letters evaluated the benefits of a ketogenic diet in 78 cancer patients in clinical practice.  A novel marker measuring the tumor cells use of glucose called transketolase-like-1 (TKTL1) was closely monitored, as was each of the 78 patients adherence to a ketogenic diet.  Increased TKTL1 was noted in more aggressively active and growing tumors (7,8).

Among the 43 males and 35 females, 7 patients agree to and followed a fully ketogenic diet and 6 of them followed a partially ketogenic diet.  Ketogenic meals were provided by a German company called Tavarlin that would prepare and mail ketogenic meals including oil, fat, snacks, bread, protein and energy drinks.  Dietary journals were reviewed every three months over a period of about 10 months.

40 % of these patients experienced a halting of the tumor progression and 60% experienced improvement noted by normalization of TKTL1 or reduction in TKTL1, respectively.  Those on a ketogenic diet demonstrated an average reduction of TKTL1 by approximately 50%.

This is the first study of its kind and has significant potential.  Could dietary carbohydrate restriction be an effective cancer treatment or adjunct to cancer treatment?

Because the food diaries were based on reporting only, the sample study was very small, and patients treated in the outpatient setting have the possibility of variability in the standard oncologic treatments,  the results must be interpreted with caution.  However, the data is very promising.   This study is one in which I have great interest as I have seen similar results in my clinic on a case by case basis.

Based on the limitations noted above, rigorous randomized control studies are needed, but this is an exciting an promising first step.  Additionally, the presence of a marker for tumor growth that correlates with diet is remarkable.  And, it provides the ketogenic specialist a possible measurement tool that could be used clinically.

 

References: 

  1. Klement RJ and Kämmerer U: Is there a role for carbohydrate restriction in the treatment and prevention of cancer? Nutr Metab (Lond) 8: 75, 2011
  2. Vaughn AE and Deshmukh M: Glucose metabolism inhibits apoptosis in neurons and cancer cells by redox inactivation of cytochrome c. Nat Cell Biol 10: 1477-1483, 2008.
  3. Gunter MJ, Hoover DR, Yu H, Wassertheil-Smoller S, Rohan TE, Manson JE, Li J, Ho GY, Xue X, Anderson GL, et al: Insulin, insulin-like growth factor-I, and risk of breast cancer in postmenopausal women. J Natl Cancer Inst 101: 48-60, 2009.
  4. Paoli A, Rubini A, Volek JS and GrimaldiKA: Beyond weight loss: A review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr 67: 789-796, 2013.
  5. Ruskin DN and Masino SA: The nervous system and metabolic dysregulation: Emerging evidence converges on ketogenic diet therapy. Front Neurosci 6: 33, 2012.
  6. Jansen, N., Walach, H.”The development of tumours under a ketogenic diet in association with the novel tumour marker TKTL1: A case series in general practice”. Oncology Letters 11.1 (2016): 584-592.
  7. . Schwaab J, Horisberger K, Ströbel P, Bohn B, Gencer D, Kähler G, Kienle P, Post S, Wenz F, Hofmann WK, et al: Expression of Transketolase like gene 1 (TKTL1) predicts disease-free survival in patients with locally advanced rectal cancer receiving neoadjuvant chemoradiotherapy. BMC Cancer 11: 363, 2011.
  8. Zhang S, Yang JH, Guo CK and Cai PC: Gene silencing of TKTL1 by RNAi inhibits cell proliferation in human hepatoma cells. Cancer Lett 253: 108-114, 2007

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

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

The Ketogenic Antidote to Chronic Renal Disease

It is well know that one of the most profound complications of diabetes is damage to the kidney and the very small arteries within the kidney acting as your body’s filtration system.  The kidney begins to lose the ability to adequately filter and retain microscopic protein progressively over time. As the blood sugar and insulin levels continually rise over time in the patient with diabetes or pre-diabetes, damage to the delicate filtering system of the kidneys occur. This very common and progressively damaging problem is called “nephropathy.”

nephropathy kidney
Chronic elevated blood sugar and insulin cause the filtering system to become more and more “leaky” and ineffective.

We knew in 1972 that patients with diabetes had thickening of the basement membrane or endothelium of the small tubles within the kidneys.  In fact, 98.6% of diabetics tested had thickening of this area of endothelium and tubules also called the renal glomeruli (1).  This allows the glomerulus or filtration system of the kidney to become more “leaky” and microscopic protein loss begins to occur through the kidney.  This loss of important proteins in the blood is called “albuminuria” or “micro-albuminuria.”  It is a flag that further damage of the kidney can and will occur without making significant changes to lower the blood sugar and the insulin. As of today, it is not totally clear how the basement membrane is damaged at the microscopic level, however, there is some evidence that elevated insulin has both a physical and immune type effect that stimulates oxidative stress, atherogenesis, immunoglobulins, as well as the formation advanced glycation end products leading to endothelial wall damage (2).

Recent research reveals that a ketogenic diet effectively repairs and/or completely reverses the albuminuria (3).

Evidence in my office of the significant improvement in micro-albumin can be seen in the one of a number of case studies below:

72 year old male with history of diabetes, diabetic nephropathy already treated with full dose statins, ACE inhibtors, metformin, and Januvia.  (Remember, microalbumin should be <30 mg/g)
Date                 Microalbumin      HbA1c
8/12/2010        2264 mg/g              6.4%   Started carb restriction <30 g per day.
10/01/2010        1274 mg/g               5.2%
1/08/2011            1198                          5.8%   Admits to cheating over holidays
12/26/2013         2434 mg/g            6.8%   Returned from 2 yr travel-off diet
2/27/2014          399 mg/g               6.3%  Restarted carb restriction <20g per day
6/20/2014           190 mg/g              7.0%  Traveling – no carb restriction
10/31/2014          280 mg/g              6.9%  Partial carb restriction <10 g/meal
3/14/2015            97 mg/g                6.8%

The patient began following a ketogenic diet in 2010.  After improvement he moved out of town for two years and “fell of the wagon.” Upon returning h restarted his carbohydrate diet and was only partially following it.  As you can see, he also admitted to some cheating on the carbohydrate restriction over the holidays.  In light of this, carbohydrate restriction decreased his albuminuria from 2400 to 97 mg/g within a period of 18 months.

References:

  1. Siperstein MS, Unger RH, Madison LL. “Further Electron Microscopic Studies of Diabetic Microagniopathy.” Early Diabetes: Advances in Metabolic Disorders, sup 1. New York: Academic Press, 1972, p261-271.
  2. Nasr SH, D’Agati VD.  “Nodular glomerulosclerosis in the nondiabetic smoker.”  J Am Soc Nephrol. 2007;18(7):2032.
  3. Poplawski MM, Mastaitis JW, Isoda F, Grosjean F, Zheng F, Mobbs CV (2011) Reversal of Diabetic Nephropathy by a Ketogenic Diet. PLoS ONE 6(4): e18604. doi:10.1371/journal.pone.0018604

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.

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

Psychology of the Ketogenic Lifestyle . . .

Ketogenic Lifestyle – the Balance of Endocrinology & Psychology

Over the last few weeks, I’ve had the pleasure of talking to a number of patients and friends about what it means to live a ketogenic lifestyle.  A low-carbohydrate or ketogenic lifestyle is different from a low-carb diet. It is different because the definition of lifestyle implies the way a person lives their life that reflects specific attitudes and values, not just how they eat. My recent posts, The Principle Based Ketogenic Lifestyle – Part I and Ketogenic Principles – Part II, focus on fundamental principles making the ketogenic lifestyle one in which balance and grounding in all aspects of life can occur.  When the mind, the body or the spirit are out of balance or un-grounded, symptoms of metabolic inefficiency, sickness or disease result. 

I have been fascinated, as a family practitioner, that the body produces “warning flags,” when there is dysfunction in one of these areas: mind, body & spirit. These warning flags are byproducts of inefficient inter-related functionality between the body’s systems and it is one of the foundation principles of osteopathic medicine.  Prior to the advent of many of our diagnostic techniques today like MRI, CT scan, advanced laboratory evaluations, and ultrasound, these were the only indicators of disease that a physician could identify, and upon which diagnosis was made. These flags often show up on the skin, in the hair or nails, in the complexion, or in general appearance or mannerisms.

Skin tags
Skin Tags (fibroepitheial polyps) under the arm

For example,”skin tags” are now recognized as pathognomonic, specifically indicative, of insulin resistance and will often occur up to 20 years before impaired fasting glucose or diabetes is ever recognized.

exopthalmos 2
Exopthalmos (bulging or protruding of the eyes) from hyperthyroidism

Exopthalmos, or protrusion of the eyes, is pathognomonnic for overactive thyroid function (hyperthyroidism), and spider angiomas occur as a somatic flag that cirrhosis of the liver is present.

Alligator Skin (severe dry skin) found in hypothyroidism
Alligator Skin (severe dry skin) found in hypothyroidism

Hair loss and dry skin, or “alligator skin,” represents the exact opposite with an under-active thyroid (hypothyroidism).

spider-angioma
Spider angioma seen with cirrhosis

When metabolic pathways get “clogged” or flow of blood, lymphatic fluid or hormones do not reach the destinations they were meant to reach, symptoms of accumulation or poor function begin to arise.

Anterior Chapman's Reflex Points
Anterior Chapman’s Reflex Points (images adapted from Osteopathic Foundations of Medicine.)

The osteopath is also trained to recognize a corollary Chapman’s Reflex Points that act as flags for dysfunction in specific organs or regions of the body. These points relate directly to what causes the pathognomonic flag.  I frequently identify abdominal, adrenal, pancreatic and liver Chapman’s points present in those with insulin resistance, inflammatory diseases, pre-diabetes and diabetes.  Understanding how to interpret and use these flags comprises four years of medical school and three to four years of residency and often years of clinical application.

Mental or spiritual pathways can often be bloc-aided by poor recognition of, or refusal to acknowledge, individual truths in our lives. Interestingly, the signs or warning flags of spiritual dysfunction are also expressed physically.

“Oh, no?! Dr. Nally are you going to get all religious on us?”

Maybe.

Over the last 15 years of my medical practice, I’ve witnessed the spiritual component of the “mind, body, spirit” unit, or lack thereof, have profound impact on the body’s ability to heal.  Every one of us must defeat what Sigmund Freud called the pleasure principle – the human instinct to seek pleasure and avoid pain, including recollections or memories that are painful.    Hiding from these memories because of pain is very common and is part of human nature.  We often believe that thinking about or re-living the truth may cause us individual overwhelming un-survivable grief.  So, we naturally bury the thoughts and emotions and feelings deep down into our subconscious minds.

In fact, we take irrational risks, busy ourselves, use food or drink for short term comfort and move from one distracting or debilitating relationship to another. We lose and then regain gain weight, become workaholics, hide behind thousands of texts, social media posts and emails in order to protect ourselves from the part of ourselves that we don’t want to think about.

However, when we step away from the distractions and courageously look at our individual history, our personal life story, honestly and completely, feelings of sadness, anxiety, regret and anger may often arise.  These painful emotions bring with them essential insights into how experiences will help you and I individually grow, become a better people, and help others along the path.  It takes faith to trust that these experiences will not destroy us, but were allowed to occur by a loving Father or Creator, understanding that for you and I to grow, we must each be given individual agency to chose.  It takes faith to recognize that that Father has your individual best interest in mind. Hiding from these emotions clogs the mental and spiritual systems and fuels disabling depression, anxiety, insomnia and fatigue. These feelings, real as they are, persist when there is no other physical sign of illness.  That’s because this illness is not physical.  It is spiritual. When we are out of line with the truths that bring peace and balance to our lives, negative, self-limiting patterns of activity and fear stifle growth and development mentally.

It is fascinating to me that on more than one occasion, as an osteopath, when a patient suffering from these symptoms gets a massage or has an osteopathic or chiropractic manipulative treatment, they may suddenly become tearful or have unexpected release of emotion. Physical treatment over the areas of congestion can, and do, cause a reflex triggering of mental, emotional or spiritual release of tensions.

How do I know that it is truth we are hiding from?  Take the words of the Buddhist teacher Sogyal Rinpoche found in The Tibetan Book of Living and Dying among many others throughout the ages:

“Saints and mystics throughout history have adorned their realizations with different names and given them different faces and interpretations, but what they are all fundamentally experiencing is the essential nature of the mind.  Christians and Jews call it “God”; Hindus call it “the Self,” “Shiva,” “Brahman,” and “Vishnu”; Sufi mystics name it “the Hidden Essence”; and the Buddhists call it “buddha nature.” At the heart of all religions is the certainty that there is a fundamental truth, and that this life is a sacred opportunity to evolve and realize that truth.”

“Wait a minute, what does all this have to do with a ketogenic lifestyle?”

The ketogenic lifestyle is one that is based on values.  A patient following a ketogenic diet recognizes that food has just as powerful effect on the hormones of the body as does prescription drugs.  Understanding the value of hormone balance and the principles that effect weight, inflammation, blood pressure and cholesterol, the ketogenic lifestyle is one in which carbohydrates are restricted in an individually tailored way to obtain the end goal. How does a ketogenic lifestyle balance mind and spirit?

Step One –

Put down your force-field.  This takes courage and it takes faith.  Your force-field is any distraction that keeps you from thinking and feeling and identifying truth.  These include excessive alcohol, illicit drugs, binge eating, smoking, gambling, working excessively or getting lost in repetitive dramatic romantic relationships .

Believe me, the force-field gets heavier every day.  After my father passed away at age 58 from the major complications of diabetes and my sister committed suicide a few years later, I threw myself into work and church service.  I worked 16-18 hour days, completed a second board certification in Obesity Management and a fellowship in Health Policy, all while serving as a bishop and counselor in my church.  I found that I could raise my force-field of justification to hide from the pain and emotions of family illness and depression.

But the force-field saps your energy and cheats you out of seeing your full potential.  I found that as long as I held up my force-field (and some of us care more than one), I couldn’t see the experiences that made me who I am and connect me with those I was trying to serve and help.  As long as I was holding up my force-field, I was living in the fear of re-experiencing the pain of loss and the worry of future disease, . . . and people sense that.

You don’t have to drop the force-field all at once. You don’t have to quit work and become a hobbit. You just have to lower the field a little bit, enough to peek over and let the Eternal Truth shine on you. Truth is a funny and powerful thing.  The more we overcome our reluctance, face the pain and the fear, the more we realize just how often things begin to go well for us.  Living in the presence of great truth and eternal law and being guided by permanent values is what keeps a man patient when the world ignores him, and calm and unspoiled when the world praises him.

Step Two –

Identify emotional or behavioral patterns that you want to change. If you don’t know, ask a trusted friend, your spouse, or your relatives. As I think back over the years, I had a couple trusted friends pull me aside and identify a few of those patterns face to face.  I appreciate that, and I’ve never forgotten it.

  1. Make a list of the events in your life that you regret and wish you would have made a different decision.
  2. Go over the list as many times as you need to to identify the pattern or theme that seems to tie the regrets together.
  3. Then actually write down the theme or reason that you identified as the cause. This allows you to identify and remove the corrupted soft-ware of your soul.
  4. This process can take time and is often camouflaged by denial.
  5. Major insight often comes as a knock on the door of denial, so listen carefully to what is being said.  Listen to yourself listening. Psychiatrists say that if something said while listening to a patient makes them suddenly feel sad or irritable, then that may be a meaningful theme in the patient’s life.  Listen to your gut feelings as you go through the day.  Don’t ignore a prompting from your soul.

Step Three –

Realize that today’s negative emotional and behavioral patterns are connected with painful memories and unsolved past conflicts.

Do you get a gut feeling that you want to change the subject when someone brings up a financial setback?  Do you want to reply with one liners like, “I’m sure it will all work out?”  Are there other topics that make you uncomfortable?  Ask yourself why that topic makes you uncomfortable . . . seriously, ask yourself, and then answer yourself.  Do you suspect your spouse of cheating when there is no objective evidence to support the suspicions?  Recognize these uncomfortable feelings are our subconscious waving flags to make us each aware of unresolved conflicts within our mind and spirit.

Remember, we attract the type of energy we give off.

Step Four –

Pray to whatever higher power you believe in.  Meditation, prayer and “ponderizing” brings a reservoir of faith and courage to find and to face the truth.  If you have the faith, get on your knees and sincerely ask God for help facing your truth and the challenges, fears and sadness that reflecting upon it may initially bring. I promise you that you will gain the strength to accomplish the task. It will bring the strength to overcome the hidden trauma in your earlier life and will give you the strength to resist the call of ice cream at 3 am.

d_day_courageFollowing these four simple steps, keeps you vigilant to the physical and spiritual warning flags that may arise on your ketogenic journey and will bring great confidence while modifying your diet to balance your body’s hormonal milieu.  Confidence inspires courage.  Those with courage and confidence in themselves, and faith that they are on the right path, are unstoppable. Good luck . . . I look forward to seeing you on my journey down the same path.

My Copy of The Ketogenic Cookbook Arrived!!!!

Look what I just got in the mail this afternoon. . . my copy of Jimmy Moore & Maria Emmerich’s The Ketogenic Cookbook! 

Wow. Great info, fantastic recipes (with amazing pictures, by the way!) and the most up to date ketogenic advise out there.  I’m impressed.

Picture 2

What a fantastic addition to my library.  I was going snap a few shots of my favorite dishes in it, but my wife picked it up while I was typing and won’t put it down. . . .

Thanks, Jimmy Moore’s Livn’ La Vida Low-Carb & Maria’s Mind Body Health!!

Chocolate Chip Food PORN

Consider yourself warned . . . !  What follows is “Low-Carb Food PORN.”  I’m not completely sure if it is just that these are catching my eye, or if my favorite Low-Carb recipe goddesses are just posting from the recipe snack bar today, but WOW! Here is a second post today about a wonderful low-carb, high fat snack.  Thank you Carolyn Ketchum.  This one has a little more carbohydrate in it ~ 6g per serving, so you have be a bit cautious on how many you consume but, just look . . .

Chocolate-Chip-Cookie-Cheesecake-Bars-3

Carolyn posted the recipe here at www.AllDayIDreamAboutFood.com.  Thanks, Carolyn!  I can’t wait to try these.

The Many Names of Sugar

Found this info-graphic while surfing Banner Health’s information pages. Many of my patients get a very confused look on their face when I ask them to restrict carbohydrates.  Sugar is the most prevalent form of carbohydrate in the Standard American Diet or SAD diet. Sugar comes by more than one name.  This info-graphic is actually very helpful.  All of these names are synonymous with weight gain and cholesterol formation.

Many names of sugar

The Truth is . . . Caloric Restricted Exercise Won’t Work

This post isn’t going to win me any friends . . .  in fact, mentioning this topic a few days ago has already angered a number of them and resulted in an online tongue lashing by a few others.  However, I can’t resist.  And, based on some very persuasive data and personal experience, I don’t care.

Obesity Trends 1971-2006
Source: http://www.health.gove/dietaryguidelines/dga2005/report/HTML/G5_History.htm

Truth is truth . . . it doesn’t change no matter how you spin it, or attempt to fit it into your paradigm.  The problem is what we have accepted in the last 40-50 years as “the scientific truth about getting healthy” is far from truth.  By getting healthy, I’m implying the application of main-stream methods accepted to lose weight, reduce cholesterol, improve blood pressure and reduce your risk of heart disease and diabetes. Live Healthy

For the last 40 years we’ve been told that the only way to get and live healthy is to restrict our calories.  This main-streamed advise continues even today in our USDA 2010 Dietary Guidelines.  And, if you ascribe to this futile dogma propagated since the 1970’s, then you’ll know that the “only acceptable way” to do this is to “eat less fat” (because fat is the most caloric dense of the macro-nutrients, right?) and to “exercise more” (because that’s how we burn calories, right?!) Well, that’s what I thought, too. And that calorie restrictionis the health prescription I doled out to my-self and to all of my patients for the first 8 years of my practice.

Interestingly, most of them, including myself, took that prescription of a caloric restricted diet of 1200-1500 calories per day and exercise 3-6 days a week for 30-60 minutes and ran with it.  Personally, I restricted calories to 1200-1500 per day and began running triathlons.  I performed cardiac monitored running, swimming and cycling for an hour a day during the week and 2 hours on the weekend.  I lifted weights 2-3 days per week as well.  Guess what it got me?  Calorie Balance ScaleFat.

It raised my triglycerides by 100 points, elevated my LDL-C and increased my waistline by 3 inches.  Yes, I gained weight.  But, hey, my doctor was happy because my HDL-C went up by 4 points.

I saw this identical pattern with 3/4ths the patients in my office. A fourth of my patient’s (the group without any genetic insulin resistance) saw weight loss and improvement in their cholesterol profiles, but the rest didn’t.  I had the exciting opportunity to introduce the saddened and discouraged 3/4ths of my patients to STATIN drugs and blood pressure medications.  My average patient’s gained 2-3% of their body fat each year. Those that exercised like fiends were lucky if their weigh gain just stabilized. Waist-Circumference-Better

What I saw in my office over a period of eight years was that exercise and caloric restriction didn’t work.  But I couldn’t say that, because that goes against everything your 8th grade health teacher taught you.  It contradicted your neighborhood dietitian, and it spat in the face of the food pyramid and the USDA Guidelines. The Government wrong?  Never. . . .  Speaking contradictory of the calorie-in/calorie-out exercise dogma was heresy, right?  Contradict, Dr. Ornish, wouldn’t be heard of?!!

If I’ve learned one thing in my medical career, it is this: “Don’t be afraid to question everything” – even Dr. Dean Ornish, the USDA and the American Heart Association.  And, fascinatingly, I’m not the only on that did.
——

——

Three Massive Studies did just that . . . question whether this exercise and caloric restriction dogma really works.  This is what applying exercise and caloric cutting did for almost 67,000 people between 1972 and 2010 – little to nothing.

WHAT?!!  Nothing?!   You can’t be serous?

The first of these trials was the MRFIT (Multiple Risk Factor Intervention) Trial.  It started in 1972, looking at 12,866 men with high risk for heart disease and followed them over seven years.  All of them were placed on caloric restricted low fat diets and encouraged to exercise.  It demonstrated that low fat diets and exercise FAILED to reduce weight or stop coronary artery disease in 100% of the cases. Don’t believe me?  Read it for yourself (JAMA. 1982; 248 (12):1465-1477).

The second of these trials was the Women’s Health Initiative (WHI).  This study started in 1991 and followed 48,835 women (yes, that’s a small city of women) for eight years.  They didn’t believe the MRFIT results apparently, so they had a low fat (caloric restricted) arm and a control arm [the SAD diet (Standard American Diet)].  The women on the low fat arm lost a whooping 0.4 kg over the 8 year period (JAMA. 2006 Jan 4;295(1):39-49).  0.4 kg, really!?? That’s almost an entire pound of weight loss over 8 years.  Quick, call Barnes & Noble so we can package that diet and sell it on Opra!!  (Oh, wait, the news media was a little embarrassed by the findings and never really mentioned them.)

Lastly, if research on 60,000 men and women wasn’t enough to demonstrate what most primary care physicians seen in their offices daily, we had to do the Look AHEAD Study (Action for Health in Diabetes).  This study started in 2001 and was supposed to run for 13.5 years.  It studied 5,145 Type II diabetic patients with intensive lifestyle intervention. These patients were placed on intensive caloric and fat restriction of 1200-1800 calories per day with exercise and behavioral counseling.   It was so unsuccessful, that they stopped the trial at 9.6 years – cause it wasn’t working.

The patients did lose some weight through Look AHEAD . . . an average of 6% of their body fat (That means you would have lost 15.6 lbs over 9 years if you weighed 260 lbs. Successful? . . . NOT).  What made this trial worse is that it didn’t improve risk for coronary artery disease and people didn’t live longer (N Engl J Med 2013; 369:145-154).  They just got the exciting chance to eat cardboard for 9 years of their lives.  Sad. Very sad.

Moment of silence

So, what does all this mean?  Exercising your brains out at an expensive gym every morning won’t do much more than help you loose 1% of your body fat.  It won’t increased your life span and it won’t decrease your risk of heart disease, despite what Dr. Ornish said.  If you like spending $40 per month just to stare at sweaty fat bodies jumping up and down in spandex, by all means, please keep going to the gym.  But I’d much rather spend that $40 on a nice rib eye steak at a restaurant staring at my wife.  But, the benefits of saturated fat . . . that’s for another post.

Don’t get me wrong.  I love lifting weights. I love riding my horse. I truly enjoy working in my yard. I even enjoy riding my bicycle.  But I do these things now because they bring me peace, decrease my stress, and allow me to connect with nature.  Believe me, there’s nothing natural about a 250 pound man in spandex staring at himself in a mirror repetitively lifting 30 pound bars of iron. But, we won’t go there.Dont Fear Fat

My friends, and a few of my patients, get their knickers in a wad trying to decry the fact that I’m giving people a reason not to go running.  Maybe I am. To be honest, there’s really only one reason I want to run, . . . and that’s when I’m being chased by a bear.  But what good does it do to guilt a person into participation in an activity that isn’t really benefiting their health or help them lose weight, unless they really truly enjoy the activity for the sake of the activity?

Our health is not based upon a caloric scale of inputs and outputs.  We are hormonal machines. We gain or lose weight and we gain or lose muscle based on powerful hormone signals, specifically insulin.  Simple carbohydrate restriction has profound effects upon our weight, blood pressure, cholesterol and inflammatory states.  Until we each come to grips with the fact that the food we eat triggers hormone responses in our bodies, we will continue down the path of diseases of civilization.  Hippocrates summed it up when he said, “Let food be thy medicine, and let medicine be thy food.”

Why Your Oatmeal is Killing Your Libido

Have you noticed that there are a large number of advertisements in the media about checking your testosterone or “Low T” Syndrome?  It seems like this is the new advertising trend on the radio and late night TV.

Suddenly, everyone’s testosterone is low and men are complaining about their libido,  . . . or are they?

Low testosterone
Benefits of Testosterone Optimization. (Image Credit: ArtOfManliness.com)

If you practice medicine long enough, you’ll see a trend that seems to have arisen as our waistlines have expanded.  About half of the men in my office with insulin resistance, pre-diabetes or diabetes have low testosterone levels.  But this shouldn’t be a surprise.  Type II diabetes, metabolic syndrome and insulin resistance are all driven by an over production in insulin in response to a carbohydrate load in the meal. Patients with these conditions produce between two to ten times the normal insulin in response to a starchy meal. A number of studies both in animal and human models demonstrate that insulin has a direct correlation on testosterone suppression in the blood. This has been demonstrated in both men and women.  In fact, glucose intake has been shown to suppress testosterone and LH in healthy men by suppressing the gonadal hormone axis and more predominant testosterone suppression is seen in patient with insulin resistance or metabolic syndrome.

Image Credit: http://www.townsendletter.com/July2012/metsyndrome0712.html
Image Credit: www.townsendletter.com/July2012/metsyndrome0712.html

In fact, to put it simply, insulin increases the conversion (aromitization) of testosterone to estrogen in men (it does the opposite in women).  Interestingly, Leptin resistance has a similar effect.  I tend to see the worst lowering of testosterone in men with both insulin and leptin resistance.

How to you improve your testosterone?  Supplemental testosterone has been shown to help, but it comes with some risks, including prostate enlargement and stimulating growth of prostate cancer.  The most natural way to improve your testosterone is to change your diet.

A low carbohydrate or ketogenic diet turns down the insulin production and allows the testosterone to be available for use by the body. A ketogenic diet has the effect of reducing leptin resistance as well through weight loss.  A simple dietary change of this type is frequently seen in my office to increase testosterone by 100-150 points.

KetoOS
KetoOS – Drinkable Exogenous Ketones

What is a ketogenic diet?  It is a diet that restricts carbohydrates to less than 50 grams per day, thereby causing the body to use ketones as the primary fuel source.  So, for breakfast tomorrow morning, hold the oatmeal (1/2 cup of Quaker Instant Oatmeal is 31 grams of carbohydrates) and have the bacon and eggs.  And, rather than have the cheesecake for desert this evening, have an extra slice of steak butter on your rib-eye and hold the potato.

Why Does Your Chicken Salad Stop Weight Loss?

I have multiple patients that come to my office that we follow and treat for weight loss and metabolic syndrome.  They are discouraged that their weight loss has stopped or is very, very slow.  The most frequent problem I find when they bring in their food journals is the “healthy chicken salad.”

“What?! But, Doc, Chicken Salad is healthy?! RIGHT?”

The chicken salad shows up on their journal almost daily.  Somehow, we’ve been indoctrinated that the chicken salad is good for us.  I want you to look closely at the image that was recently shared on the internet below.  How is the nutrient value of your chicken salad any different than the Big Mac?

Burger Salad Comperison

Why is this unhealthy?  The carbohydrate content greater than 20-30 grams will cause a spike in insulin.  When insulin spikes, the body is told to store fat (and it will store fat for up to 12 hours) . . . Yes, the 24 grams of fat in the salad now become dangerous in the presence of an insulin spike.  In my patients with metabolic syndrome, they will produce between two and ten times the insulin and store two to ten times the fat. (Ten Big Macs would have tasted better . . . )

There is actually more carbohydrate in your salad than in the big mac.  Why not add a strawberry shake just to finish putting the nail in the coffin?  And we wonder why we are having trouble with weight loss?

The other issue, and probably of even greater importance, is that chicken breast has the second highest content of lysine & argenine (two of the 10 essential amino acids) count of all the poultry family.  This is second only to turkey breast, which also contains a large amount of tryptophan (a third essential amino acid that spikes insulin).  Why is this a problem?  Because argenine, tryptophan and lysine all stimulate an insulin response on their own, separate from glucose.  We need these amino acids, however, when our meals contain a predominance of these amino acids, it rasies insulin significantly in those who are insulin resistant (pre-diabetic).

Those 43 carbohydrates, plus the stimulus from a meat high in argenine, lysine and tryptophan, spike your insulin, kick you out of nutritional ketosis and slow weight loss for up to 48 hours.

Please, if you are following a low-carb or ketogenic diet, get rid of the chicken salad.

If you want to learn more about this, read my article on the eight most common reasons you can’t lose weight.

Carb Thoughts

A number of patients come in to the office struggling with loosing weight.  When I review their dietary journals with them, I notice that many of them never stop eating fruit (because, fruit is good for you, right?!).  Well, lets put it this way:

One banana for breakfast is equal to . . .

banana

. . . just over seven (7) teaspoons of sugar.

teaspoon sugar

Count them . . . seven (7) teaspoons.

If your eating a banana for breakfast, it is halting your weight loss for up to 12 hours.  Give the banana’s to the monkeys and cook up some sausage and eggs for breakfast tomorrow.

Fat Thoughts . . .

As a bariatrician, I think about fat all the time.  I guess you could say I have a lot of “fat thoughts.”

I frequently hear patient’s tell me, “Dr. Nally, I’m eating RIGHT, but I’m just NOT losing weight!”

If you’re not losing weight, your not eating correctly. 99% of your weight loss success is related to your diet. We have been poorly misinformed over last 40 years as to what a “correct” diet contains. We’ve been told to follow a low fat diet for the last 40-50 years.  However, it is very apparent as patient’s follow a low fat diet that only a small percentage of them have success in weight loss, and the majority actually gains more weight and remains significantly hungry.  When you look at the body’s physiology, fat restriction only stimulates increased hunger.  The intake of any form of carbohydrate, whether that be simple or complex, stimulates an insulin response.  Based on our genetics, that insulin response can be variable. some of us respond normally and others respond with between 2-10 times the normal insulin surge.  Insulin is actually the hormone that drives weight loss or weight gain.
You and I will not be able to effectively lose weight until we control the response of insulin, and this can only be done through carbohydrate restriction.