Tag: Ketogenic Diet

October 6, 2015

The Principle Based Ketogenic Lifestyle . . . Part I

It has been resoundingly clear to me over the last couple of weeks that there is a tremendous need for a principle based approach to a ketogenic diet. This approach, however, must be simple. So many of the approaches to weight loss I read about are complex and the questions that arise from these approaches are innumerable. Losing weight should not be as difficult as putting a man on the moon. To quote a patient recently, “If it ain’t simple, Doc, I ain’t doing it. . .”

I agree.

Any approach that requires the conversion of food to numbers or calories or exchanges becomes cumbersome, and I personally won’t follow it for more than a week. The principle based approach should be simple and is really based upon the mantra:

Give a man a fish and he will eat today. Teach a man to fish and he will eat for the rest of his life.

Ketogenic diets are wrongly referred to as diets. What I’m talking about is a ketogenic lifestyle. Simple lifestyle design should not be hard. So, what do you say? Shall we learn to fish?!

I assume that if you’re reading this article, you already understand that weight gain is not due to an over intake of calories. Weight gain is due to hormone signals throughout the body leading to the storage of fat . . . specifically, triglycerides being taken up into the fat cells. The hormone that independently controls uptake of fat into each fat cell is insulin. Insulin is an essential hormone, but too much of it stimulates the adipose (fat cells) to over-stock triglycerides or essentially “get fat.” It, actually, is that simple. There’s really only one rule to this lifestyle: If it raises your insulin it will halt or stall your weight loss. Write that on your hand or your forehead or in your planner, the lifestyle revolves around that one rule.

Most people start a ketogenic diet because they want to lose weight and have failed at multiple other dietary approaches. Reasons for weight control failure are often multi-faceted, but they all start with from a position of flawed understanding. The majority of approaches to weight management come from the false assumption that weight is gained because of an over-consumption of calories or a lack of physical activity to burn excess calories. People have faithfully been restricting calories and exercising to exhaustion since the early 1980’s to no avail. (Well, 1% of people succeed, but the rest of us failed this approach). The definition of insanity is repetitive completion of an ineffective action and expecting a different outcome each subsequent time around. If you still think that caloric restriction and exercise is successful, I’ll be shipping your drawstring white vest and your invitation to a padded cell shortly.

Let me put it clearly. We’ve been exercising and cutting our calories since 1975 and look at what it’s gotten us . . .

. . . . a country that is now recognized as the “United States of Corpulence.” Super-Size me has become literal. “Houston . . . we have a problem . . . !”

The rule above is based on foundational principles. Understanding of the principles allows one to successfully apply the rule above.

PRINCIPLE 1

The first principle in a ketogenic lifestyle is understanding that the problem is not caloric, but hormonal. Choices and actions from here on out must be based on this understanding. Anything that will raise insulin will thwart ketosis. Insulin stimulates lipoprotein lipase, the enzyme that pulls the triglycerides into the fat cells. Without insulin, we don’t gain weight. (That’s why type I diabetes are usually very slender and skinny).

The standard lab value for normal fasting insulin levels reflect 10-22 uIU/L as the normal. However, in my office, glucose tolerance tests and postprandial glucose tests consistent with impaired fasting glucose are routinely positive when the fasting insulin level is >5 uIU/L.

Point of Focus: If your having trouble, look at the hormones. Food stimulates hormone responses. Focus on the hormone response to your diet.

PRINCIPLE 2

A ketogenic diet is one where the body uses fatty acids as the primary fuel. Those triglycerides mentioned above are made up of three fatty acids linked to a glycerol molecule. To use the triglycerides, the three fatty acids must be broken away from the glycerol by hormone sensitive lipase (HSL). Insulin directly inhibits HSL. Keeping insulin levels low is the first step in shifting to a ketogenic metabolism. Lowering insulin allows access to the fatty acids in your fat cells. Triglycerides are not water soluble and the rate by which they can be taken up and burned in the mitochondria limits the speed by which triglycerides can be used as fuel. The by product of triglyceride burning is ketones. Ketones themselves can be used as fuel and over 4-6 weeks, the body can enhance its ability to use ketones when fat is the primary fuel. This is called “Keto-Adaptation.”

Point of Focus: Too much carbohydrate in the diet shifts the body from it’s use of fat and triglycerides back to glucose. In general, to become “keto-adapted,” limit carbohydrate to < 20 grams per day. Keep protein at around 0.8 to 1 gram of protein per pound of body weight.

KetoOS – Drinkable Exogenous Ketones

PRINCIPLE 3

Wait a minute!? Where do the ketones come in? When fatty acids are burned or oxidized in the mitochondria of cells within the liver, they are converted into Acetyl-CoA. The Acetyl-CoA is used to form ATP for energy in the Citric Acid Cycle.

IF excess Acetyl-CoA production occurs or if inadequate oxaloacetate is present, the extra Acetyl-CoA is transformed into ketone bodies – specifically beta-hydroxybutyric acid and acetoacetic acid. Fat can be oxidized or burned for fuel while ketones are being produced. Ketones are much smaller molecules and can more easily be transported in the blood than triglycerides, as they are water soluble. The ketones themselves can also be used or burned as fuel as the body upregulates the mitochondria’s ability to use the ketones as fuel as well. As I mentioned above, this process of “keto-adaptation” can take 4-6 weeks. Keto-adaptation results in humans having a greater desire to be physically active – the miraculous conversion of the couch-potato into the bacon-burning triathlete.

Point of Focus: Sugar is a drug. Its byproduct has the same hedonic effect on the brain as morphine. Sugar withdrawal can commonly cause headache, anxiousness, insomnia, dizziness, fatigue and moodiness within the first week of carbohydrate restriction on the road to keto-adaptation.

PRINCIPILE 4

For the average person to become “ketotic” or reach a state of ketosis, it takes lowering the carbohydrates to less than 20 grams per day (and sometimes less than 10 grams per day) for at least 3-7 days. Yes, it can actually take a week to reach ketosis. I have a few patient’s that are so insulin resistant that it takes longer. This means that to reach that fat burning state, one must maintain a low insulin response by restricting starch or carbohydrate intake to less than 20 grams per day for a minimum of a week. For your body to efficiently use the fuel it can take up to 6 weeks. This is why many people state that they “don’t feel good” or “can’t maintain their exercise levels” when starting a ketogenic diet. For most people, once they reach the 6 week mark, mitochondria have been unregulated and “fine tuned” to burn ketones, fat burning becomes efficient and energy levels begin to increase. In fact, for many like myself, you’ll finally feel like exercising for the first time in you life.

Point of Focus: If you’re already exercising, don’t be surprised if you feel more sluggish for the first four weeks. If you’re not exercising, I don’t recommend starting until after you pass through the Keto-Adaptive phase.

PRINCIPLE 5

Clinically, the average patient in my office will lose 5-15 lbs each month for the first three months. Then the weight loss will slow to 2-5 lbs per month. However, 1/2-1 inch continues to disappear off the waist circumference measurement every month. THIS IS NORMAL. Continued weight loss of 15 lbs a month will leave you looking like the Michelin Tire Man – rolls of skin without fat. The body slows the weight loss to keep up with skin and connective tissue remodeling. As long as ketosis is maintained, the fat will continue to melt away. At this point, I’m not so worried about scale weight as I am your waist circumference.

Point of Focus: Successful ketosis does not always affect the scale, but usually causes your pants to fall down.

PRINCIPLE 6

It has been my experience that it takes about 18 months for the average patient to reverse the insulin resistance while following a carbohydrate-restricted, high-fat ketogenic lifestyle. There is no quick fix for this. If there was, I’d be sitting on a beautiful beach in the Caribbean.

Point of Focus: The Ketogenic dietary lifestyle is actually the antidote to insulin resistance, diabetes and the diseases of civilization.

PRINCIPLE 7

Improvement in insulin resistance has also been demonstrated with mild to moderate intensity resistance exercise. Moderate intensity resistance exercise is 20-30 minutes of exercise like walking, easy jogging, cycling, lifting weights, yoga or Pilates with speeds or weight heavy enough to break a sweat, but not so fast or heavy that you cannot carry on a conversation with your exercise partner. Exercise improves insulin resistance – BUT IT DOESN’T CAUSE WEIGHT LOSS! Yes, I know, Jack LaLanne just rolled over in his grave. But, let me say that again. Exercise improves insulin resistance, but it does not improve weight loss!! The three largest and most intensive studies of exercise involving over 67,000 people demonstrate that you can exercise till the cows come home and you’ll average about 1% weight loss. If you exercise, realize it WILL make you hungry. Eating the wrong food (carbohydrate containing foods) will stimulate insulin release causing your exercise to be fruitless (Actually, your diet should be “fruit-less” anyway)

Point of Focus: Exercise because you feel like it, it improves insulin sensitivity and it decreases stress, not for weight loss.

PRINCIPLE 8

If you are eating enough fat, you won’t be hungry. Although this doesn’t always hold true in the case of patient’s with lepin resistance. 40-60% of patients with insulin resistance have a concomitant leptin resistance (see the article on lepin resistance here). A ketogenic diet is one in which 50% or more of total calories come from fat. No, you don’t have to count calories, just pick foods that contain 45% fat or more. Look for grass fed products as they will be higher in Omega 3 fatty acids. Red meat is 55% fat. Pork is 45% fat. This is where the chicken salad or turkey wrap fails (see Why Does Your Chicken Salad Stop Weight Loss). Look for alternatives to replace your basic meals and snacks. If you love chips, try pork rinds or make chips from fried cheese or pepperoni. Guacamole is a great replacement for bean dip.

Point of Focus: There is no need to eat 3-6 times per day. As you increase the fat in your diet you will feel more full. Eat when you are hungry, whether that is 3 times a day or once day, listen to your body.

PRINCIPLE 9

I’ve been following a ketogenic diet for over 10 years. The most common complaint I hear is, “Dr. Nally, I’m tired of eating eggs.” Ketogenic diets don’t have to be boring. There are hundreds of resources on the web for spicing up your ketogenic diet. See the Recommended Sites page above for some ideas to start. The Ketogenic Cookbook by Jimmy Moore and Maria Emmerich is a recent edition to the literature and a fantastic resource. Check out Franziska Spritzler’s Low Carb Dietitian website and new book as well. If you live in the UK, you should see Emily Maguire’s website and blog. She just completed a world tour, sampling all the low carbohydrate foods and restaurants around the world. If you are a picture person, check out the Best Keto Meals of 2015 Pinterest page followed by almost 16,000 people. If you haven’t takent the time, you should visit Dr. Andreas Eenfeldt’s website. He is one of Sweden’s premier ketogenic doctors has an immense number of resources at his website, Diet Doctor. Finding someone that can help you fine tune your diet is also essential. You can find a list of doctors that use ketogenic diets here.

Point of Focus: This lifestyle will require you to use real, whole food and cook like your grandmother or great grandmother did in the past. Unfortunately, we’ve lost a great deal of the art of cooking that needs to be re-discovered. If your lifestyle is too busy to cook and prepare real food, that busyness is probably causing you stress, another culprit in the weight gain cycle. The truth will set you free, but it will probably make you miserable first.

PRINCIPLE 10

WARNING! A very sweet patient of mine was given these instructions to treat her weight and blood sugar abnormalities. She applied these principles and they worked marvelously. She called me a few weeks later, however, mad as a wet hen. She placed her husband (not my patient at the time) on the same dietary changes. Her husband, who had significant blood pressure problems and was on four different blood pressure medications I later found out, had a sudden drop in his blood pressure and passed out. As happens to many of my patients, blood pressure, ejection fraction of the heart and blood sugars quickly begin to normalize. However, he never saw his doctor and never had is blood pressure medications adjusted. Because of the normalization that can occur in as rapidly as 1-2 weeks, the medications became much too strong, he passed out and ended up in the emergency room. These dietary principles are effective. They are often just as powerful as a number of the medications that we routinely prescribe.

Point of Focus: Please see your doctor before beginning any of these dietary recommendations, especially if you have any underlying medical conditions including Hypertension, Diabetes, Congestive Heart Failure, Coronary Artery Disease, Gout, Kidney Stones, etc., please do not try the dietary changes alone. Find a physician trained in the use of this type of dietary lifestyle in combination with close monitoring of your blood pressure, blood sugar and other key vital signs.

Stay tuned for Ketogenic Principles . . . Part II in the series where we’ll address Food Psychology, To Cheat or Not to Cheat, and Keeping it Real . . .

October 4, 2015

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

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

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

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

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

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

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

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

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

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

“There appears to be a conscience in mankind which severely punishes the man who does not somehow and at some time, at whatever cost to his pride, cease to defend and assert himself, and instead confess himself fallible and human. Until he can do this, an impenetrable wall shuts him out from the living experience of felling himself a man among men. Here we find a key to the great significance of true unstereotyped confession – a significance known in all the initiation and mystery cults of the ancient world, as is shown by a saying from the Greek mysteries: ‘Give up what thou hast, and thou will receive.'”

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

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

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

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

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

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

October 1, 2015

Dr. Nally Featured on Periscope – Jimmy Moore's 100th Broadcast

My Special 100th #Periscope: Announcing A Brand New #Keto Podcast With Me & Dr. Adam Nally #JimmyScopes JimmyScopes.com from Jimmy Moore on Vimeo.

Today’s Periscope with Jimmy was a teaser for what is to come. I will be joining Jimmy Moore to create a new weekly podcast to address “Keto Questions” you may have. Stay tuned for more information . . .

September 30, 2015

Cinnamon Swirl Cheese Cake . . . (I think this will be a desert on the menu in Heaven)

While at the house last night, Jimmy Moore, his wife Christine, and my wife Tiffini made this delicious cinnamon swirl cheese cake from The Ketogenic Cookbook. I think I have a new favorite!!! I seriously have not had a better cheesecake and this one is lowcarb, gluten free and keeps you in ketosis. Thank you Jimmy Moore and Maria Emmerich for such a yummy recipe. (I even had some for breakfast this morning . . . . mmmmm).

If you want a great low carb recipe, pick up a copy of the book and turn to page 336.

Until next time . . . keep the ketones high!

September 27, 2015

Jimmy Moore visiting Nally Family Practice . . .

The amazing Jimmy Moore and his wonderful wife, Christine, will be stopping by my office on Monday, September 28th, 2015, between the hours of 9 am and 1pm. Jimmy Moore, Podcaster for Livin’ La Vita Low Carb and author of The Ketogenic Cookbook, KetoClarity and Cholesterol Clarity has been in Phoenix this weekend and agreed to visit the office.

I have been recommending his books and website to my patients for years. His website, books and podcasts have served as superb resources for Low-Carb, High Fat and Paleo dietary programs and patients just starting or fine tuning their programs.

Jimmy and his sweet wife, Christine, have become great friends and trusted colleagues over the years as new science and treatment protocols have been identified in the treatment of obesity, insulin resistance and diabetes. He has been a resource for me and my patients for over 10 years.

Pick up your copy of these books at Barnes & Noble or your favorite nearby bookstore; and if you are in the neighborhood and would like meet Jimmy, bring your copy of the Ketogenic Cookbook, KetoClarity or Cholesterol Clarity to get signed and shake his hand.

If you haven’t checked out his podcasts on Livin’ La Vita Low Carb, or seen his Periscope casts on JimmyScopes.com you need to click on the links and check them out.

September 23, 2015

The Power of a Good Vitamin

“So, Doc, which vitamin should I take?”

I’ve heard this question at least 5-6 times per day for the last 20 years. The problem has been, there hasn’t been just one or two products that fit my or my patient’s needs. I’ve seen many that are close, but no one seems to understand the needed nutrients for insulin resistance, leptin resistance and the tremendous effect adequate nutrients has on inflammation, atherosclerosis, uric acid, sodium balance, cholesterol and blood pressure. That is, until I found a company that would let me design my own vitamin.

Working with a world renowned lab, I put together what I know to be the best ketogenic multivitamin on the market. I give you the “KetoNutritionals Multivitamin.”

It provides the nutrients that we recognize are essential to the TCA (tricarboxylic acid) or Krebs cycle. I call it the Multivitamin Adult Formula, because it has the potential to enhance the body’s ability to use insulin, leptin and regulate normal blood sugar and maintain ketosis. Now, it is essential that I inform you that these statements have not been evaluated by the FDA and that this product is not intended to diagnose, treat, cure, or prevent any disease.

Methylated Folic Acid

However, 60-65% of pre-diabetic and diabetic patients I see in the office do not correctly convert Folic Acid (Vitamin B9). It is suspected that over 40% of the population in general has a genetic deficiency in the gene that codes for MTHFR. MTHFR (also called methylenetetrahydrofolate reductase) is a genetic sequence that encodes for an essential enzyme in your body that helps make the active form of folate. Your body cannot make folate on its own, so it requires enzymes including the one encoded by the MTHFR gene, to make it from the foods that you eat. MTHFR enzyme also has an important role in making amino acids, the building blocks of proteins, by helping convert the chemical homocysteine to methionine in concert with Vitamin B12. Homocysteine is a harmful chemical made by your body that can damage the lipid membrane of cells leading to damage of the walls of your blood vessels, and may affect your blood clotting. In contrast, methionine is an amino acid required by your body for normal functioning. Supplementing the methylated folate helps to provide the needed components for methionine production. KetoNutritional Multivitamin contains both forms of active isomer, naturally occurring folates. MTHFR deficiency can easily be tested for through a simple saliva test in the office.

Metabolism of folate and homocysteine. American Journal of Physiology – Heart and Circulatory Physiology Published 1 July 2004 Vol. 287 no. 1

The conversion of methionine to SAMe is essential in this pathway. SAMe (pronounced Sammy) is necessary for methylation. It is essential in the formation of neurotransmitters like serotonin and liver detoxification through the methylation pathway. Serotonin is key in the treatment and prevention of depression, chronic pain, and liver detoxification. In a number of cases, just fixing this methylation has dramatically improved symptoms of depression that would have otherwise been treated with strong psychogenic medications.

N-Acytylcysteine

Cysteine is used by the body as a source of sulfur for detoxification and the production of glutathione. Glutathione is your body’s chief anti-oxidant and protector against all kinds of damage. This is where Vitamin B6 plays a major role. Vitamin B6 is also a cofactor in hundreds of different chemical reactions necessary for healthy hormones like estrogen, and progesterone. It is also essential for the production of neurotransmitters like serotonin, dopamine, and GABA for proper brain function.

Carnosine

KetoEssentials contains the essential vitamins to allow these metabolic pathways to function properly. May people on a ketogenic diet don’t get the full effect of weight loss until adequate Vitamin B12 and Vitamin B6 are supplemented. It also contains Vitamin B1, and carnosine that have been found to decrease the effect of inflammatory glycation and damage caused by higher blood sugars like diabetic retinopathy. High gamma Vitamin E has also demonstrated retinopathy protection.

Alpha Lipoic Acid, Taurine, ECGC

Alpha lipoic acid combined with biotin has been shown to augment a more natural, healthy insulin secretion thereby promoting a more effective glucose metabolism. Taurine, epigallocatechin gallate (EGCg) from green tea and Vitamin D have all been shown to improve the effect of the insulin you produce.

Improving insulin use and production has a direct effect your triglycerides. We now know that when your triglycerides are “out -of-whack,” leptin transport across the blood brain barrier is affected and this worsens your risk leptin resistance. Leptin is that amazing hormone that tells your brain that your fat cells are “full” and to stop eating.

Vitamin A

Vitamin A as a carotenoid acts helps aid immune function and Molybdenum aids in detoxification processes in the body.

Zinc

Added zinc, taurine and EGCg to reduce the damaging effects that fructose can have in the liver, and also enhancing your insulin signaling. Added zinc also helps stabilize your testosterone and sex hormones.

Chromium, Manganese, Vanadium

But, these vitamins and anti-oxidants don’t help if they’re not absorbed correctly, so magnesium, chromium, zinc, manganese and vanadium help to enhance absorption. Correct supplementation of these nutrients may have the effect of normalizing glucose, insulin and leptin levels an reduction in risk for long term cardiovascular disease, diabetic complications, water retention, and more effective weight loss.

KetoNutritional Multivitamin

#180 Capsule Bottle

TO BUY YOUR BOTTLE

-> CLICK HERE <-

References:

Moat SJ, Doshi SN, Lang D, McDowell IFW, Lewis MJ, Goodfellow J. “Treatment of coronary heart disease with folic acid: is there a future?” American Journal of Physiology – Heart and Circulatory Physiology Published 1 July 2004 Vol. 287 no. 1, H1-H7 DOI: 10.1152/ajpheart.00952.2003
Hipkiss AR, Brownson . Reaction of carnosine with aged proteins: another protective process? Ann N Y Acad Sci. 2002 Apr;959:285-94.
Waltner-Law ME, Wang XL Epigallocatechin gallate, a constituent of green tea, represses hepatic glucose production. J Biol Chem. 2002 Sep 20;277(38):34933-40. Epub 2002 Jul 12.
Jacob S, Ruus P, Hermann R, Oral administration of RAC-alpha-lipoic acid modulates insulin sensitivity in patients with type-2 diabetes mellitus: a placebo-controlled trial. Free Radic Biol Med. 1999 Aug;27(3-4):309-14.
Boucher BJ . Inadequate vitamin D status: does it contribute to the disorders comprising syndrome ‘X’? Br J Nutr. 1998 Apr;79(4):315-27.
Hammes HP, Du X . Benfotiamine blocks three major pathways of hyperglycemic damage and prevents experimental diabetic retinopathy. Nat Med. 2003 Mar;9(3):294-9. Epub 2003 Feb 18.
Maassen JA, Mitochondrial diabetes, diabetes and the thiamine-responsive megaloblastic anaemia syndrome and MODY-2. Diseases with common pathophysiology? Panminerva Med. 2002 Dec;44(4):295-300.
Ozcelikay AT, Becker DJ. Improvement of glucose and lipid metabolism in diabetic rats treated with molybdate. Am J Physiol. 1996 Feb;270(2 Pt 1):E344-52.
Banks WA, Coon AB, Robinson SM, Moinuddin A, Schultz JM, Nakaoke R, Morley JE. Triglycerides Induce Leptin Resistance at the Blood-Brain Barrier. Diabetes May 2004 vol. 53 no. 5 1253-1260.

September 21, 2015

Homemade Rootbeer – Ketosis Style!!

ery October I get a hankering for homemade root beer. But it is usually loaded with sugar. Thanks to Maria Emmerich and her amazing recipes, that doesn’t have to happen this year. She just posted this on her site today and I can’t wait to try this as I sit by my fire pit roasting some hot dogs with my kids . . . Thanks Maria.

I pasted a copy of her root beer image below just to make you drool, too . . .

Link on the recipe at her site HERE.

(Another great use for the SodaStream as well . . . the day just keeps getting better!)

July 24, 2015

Handy Charts for Maintaining Ketosis

I found these charts to be very helpful when trying to calculate your fat intake with a meal. Fish can be challenging in calculating fat content. After reading these charts, I’m craving some sashimi’ed mackerel and salmon.

Great charts like these can be found at http://mariamindbodyhealth.com/charts/

Enjoy!!

July 18, 2015

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.

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!!

June 28, 2015

So, What is this Ketogenic Thing Again . . . ?

I’ve personally been following and prescribing ketogenic diets to my patients since 2005. When I started on my ketogenic journey, it was called a “Low Carbohydrate Diet.” Over the last 5-10 years, we’ve learned a thing or two about how the body processes carbohydrate, protein and fat. Specifically, it’s not just the restriction of the carbohydrates that leads to metabolic health, but appropriate protein intake and significant emphasis on the level and type of fat intake as well. The majority of people who cut out carbohydrates will initially see successful weight loss, but to maintain that weight loss and see significant metabolic changes that reverse the diseases of civilization, an understanding of protein and fat needs are essential.

It’s Not Necessarily a High Protein Diet

Most people, when they hear you’re following a “Low-Carb” diet . . . respond with, “Oh, you are on that high protein, Adkins’ thing, . . . right?!”

Well, not really. A true ketogenic diet is NOT a “high protein diet.” However, you must be ingesting enough protein to maintain muscle, hair growth and energy levels. Most people, having been brainwashed in grade school and middle school about the horrors of fat in the diet, assume that if you’re not eating carbohydrates, then you must be eating extra protein to stay satiated. (No one would ever intentionally increase the fat in their diet, right?!!) However, remember that protein and fat usually come together in the sources that the Good Lord put them in.

That’s the impression that most people in my office get when I mention the words “Low-Carb” or “Adkins.” And, before I have a chance to explain that I’m not recommending that you race home to eat three large turkey legs and a pound of turkey bacon, the vegetarians gather their things to leave and the former home economics teachers begin to get chest pain at the mental picture in their heads.

How Are Ketones Made?

A ketogenic diet is one which allows your body to use ketones as it’s primary fuel source. Ketones are produced from the breakdown of triglyceride and free fatty acids. Ketones are essentially produced by two distinctly different events:

1) Starvation caused by prolonged periods without food (which is essentially what happens to type I diabetics when they have no insulin at all in their systems)

2) When fat is ingested as the primary fuel, and very low levels of insulin are concurrently produced, primarily when the diet has minimal to no carbohydrate present (allowing the body to activate its free fatty acid reserves found within in the adipose cells).

The body is an amazing machine. It was designed to take any of the three main macro-nutrients (carbohydrate, protein or fat) as fuel and function quite well. It’s like a futuristic car that can run on unleaded gasoline, oil, or diesel fuel. It is able to recognize which fuel is present and run quite well off of any of the three. The amazing thing about the body is that we mix up all three fuel types and just pour them into the tank. Impressively, the body can separate them out and run very well in the short term on any combination of mixes. We don’t have cars or trucks that do that today . . . maybe in the future . . .?

We have Two Fuel Systems

I like to equate carbohydrates to unleaded fuel. These are clean burning, easy to access and cheap. However, the body requires the production of insulin to use this “unleaded” type of fuel. When carbohydrates are identified to be present in the liver and pancreas, insulin is released so that the rest of the cells throughout the body can “open the tank” and let the carbohydrate into the cell to be used as fuel. The challenge is that carbohydrates don’t store very well in the form they are supplied in, so, as a protective mechanism against starvation and famine, if excess carbohydrate is found in the system, it is converted into triglyceride. Insulin is required for this. Interestingly, when your insulin levels rise, the signal to the body is that “unleaded fuel” is in the system, so it stores any fats and excess carbohydrates in the form of free fatty acid and triglyceride. Carbohydrate stimulate an insulin response and cause fat storage. It is the same reason we give corn to cattle — to plump them up before taking them to market.

Fat then is the “diesel fuel” of macro-nutrients. It burns well, can be stored very easily, and provides over twice the energy to the body when measured in the form of k-cal per gram. Fat is used preferentially when there is limited or no insulin floating around the blood stream and is quickly and efficiency stored when other forms of fuel are available. (Insulin being the key hormone signaling that other fuel is around.)

Nutritional Ketosis is Using Fat as Your Optimum Fuel

So what is this “ketosis thing?” It is a method of dietary change (a lifestyle) that intentionally focuses the body’s metabolism to use fat (in the form of triglyceride & free fatty acid) as its primary fuel. Leading to weight loss, dramatically improved blood sugars, significantly improved cholesterol and triglyceride levels, and notably improved inflammatory markers.

“But don’t you end up eating a lot more protein on your weight loss program?” I frequently get asked.

Honestly, No.

Protein and fat are both very filling, and most people find that limiting the carbohydrates actually causes less hunger and diminishes the rebound carbohydrate cravings often stimulated by the two or three slices of bread, pasta or that potato often occurring 2-3 hours later. Interestingly, most people don’t eat that much more and the protein levels remain fairly constant. Because fat and protein come together in meats, eggs, fish, etc., satiation occurs with just minor increases in dietary intake real animal food. I don’t recommend increase the fat alone. I recommend increasing the amount of real animal protein until you are full. This is even more satiating and many people find themselves eating only twice a day when they are hungry.

Excessive protein in those who are morbidly obese with severe overproduction of insulin can experience a spike the insulin levels further with large amounts of protein. Protein can be equated to the oil you put in your car. Protein is a building block used for muscle, connective tissue and some essential metabolic functions. When too much protein, in this group is ingested, it spikes the insulin. (See my article on Why Your Chicken Salad is Making you Fat)

Most people have problems when they start supplementing with protein shakes. These often contain sweeteners that raise insulin and consequently halts your weight loss – or even causing weight gain.

June 27, 2015

Crispy Fat Bomb

I am always impressed by good pictures, great recipes and and scrumptious food. My wife knows this. Finding great ketogenic recipes is essential. The reason, is that to loose weight and remain in ketosis, it is often essential to increase fat intake to at least 50% of your total calories. Fat Bombs are a great snack idea that helps one accomplish this task. Increasing fat to that level can be challenging for some. Maria Emmerich has posted another tasty and tantalizing high fat, low carbohydrate snack. Check out her recipe for the Crispy Fat Bomb. This is one of those great high fat, low carb tools to keep you in ketosis.

On of my patient’s was just asking about another good Fat Bomb Recipe. So, thanks, Maria!! And, my patient’s thank you too. Try this one out. Please let me know what you think of the crispy versus Tiffini’s Fat Bombs.

May 10, 2015

Much Ado About Ketosis: Are The Adverse Effects Really That Adverse?

I recently read a blog post decrying anyone that would recommend a low carbohydrate / ketogenic diet to their patients.

What?!

In fact, this particular blog outlined a number of “adverse reactions” to a ketogenic diet, and based upon these perceived reactions, the writer advised severe caution with its use in just about anyone. It is important to note at the outset that most of the data this blogger quotes are from older studies completed in children for the treatment of epilepsy with specific liquid ketogenic dietary meal replacements. (Not what you’d expect in a low-carb / ketogenic diet for the average obese adult today.)

Diet Confusion

Thanks to recent misinformation by a number of medical professionals, including the person writing the blog referenced above, a poor understanding of fatty acid metabolism by the general community, and a distinct lack of understanding of human adaptability recorded over the last 5,000-6,000 years, there is still significant confusion about ketogenic diets.

It is important to recognize the crucial fact that the human body is designed to function quite well when supplied any of three macronutrients: carbohydrates, proteins or fats. It does so through an amazing series of enzymatic reactions referred to as the Krebs (tricarboxylic acid) cycle, producing needed ATP (adenosine triphosphate) required for our muscles to contract, our heart to beat and our diaphragm to expand our lungs. What’s even more amazing that that the body was designed to recognize the season we are in based up on the food we eat. That is, until we invented refrigerators in 1913. (Now our bodies think it’s year round summer time . . . wait . . . I live in Arizona where it is year round summer time.)

No, this is not a post about unplugging your refrigerator, living on solar, getting off the grid and saving energy.

Our bodies recognize the seasons we are in based upon inherent hormone release. The key hormone is insulin. Insulin can be looked at as the seasonal indicator to our bodies. Insulin production rises and falls based on our intake of carbohydrates (sugar, starches, some fibers). Insulin, essentially, tells our bodies when it is a “time of plenty” and when it was a “time of famine.” Why? You ask. We didn’t have refrigerators 100 years ago and you were lucky if you had a root cellar. The body needs to know when to store for the famine (the winter) that was around the corner. Insulin is that signal.

During the summer, potatoes, carrots, corn and other fruits are readily available. These are all starchy carbohydrates and they all require the body to stimulate an insulin response so that they can be absorbed. Insulin stimulates fat storage (J Clin Invest. 2000;106(4):473-481. doi:10.1172/JCI10842). Just like bears, our bodies were designed to store for the winter.

During the winter, when carbohydrates were less prevalent, insulin production could and would decrease to baseline levels. This also is a natural phenomenon that occurs with fasting and even during lactation. (Kreitzman SN. Factors influencing body composition during very-low-caloric diets. Am J Clin Nutr. 1992;56(l Suppl):217S–23S.; Medical aspects of ketone body metabolism. Mitchell GA, Kassovska-Bratinova S, Boukaftane Y, Robert MF, Wang SP, Ashmarina L, Lambert M, Lapierre P, Potier E, Clin Invest Med. 1995 Jun; 18(3):193-216.)

If you think back in history, your grandparents probably used stored meats & cheeses that could be salted or smoked for preserving during this time of year. Those crossing the plains were commonly found with pemmican, a concentration of fat and protein used as a portable nutrition source in the absence of other food. (Chapter VIII. Narrative of the Life of David Crockett, of The State of Tennessee, Written by Himself, Sixth Edition [E.L. Carey and A. Hart:Philadelphia] 1834, 1837; Marcy, The Prairie Traveler, p. 31.) Think about conversations you may have had with your grandmother when she told you that for Christmas, she received an orange. A single orange for a gift?! Many of my patients drink 12-15 of them in a glass every morning. The winter diets of our grandparents were very low in starches and carbohydrates. When carbohydrate intake is low, little insulin is produced.

Again, insulin is the hormone that tells you that you’re in “a time of plenty” and stimulates weight gain and cholesterol production to prepare for winter. Those prescribing the use of ketogenic diets understand this innate human adaptive trait, and use it to effect changes in weight, cholesterol and other desired metabolic changes.

Three types of ketones. Uptodate.com, May 2015

Now, let’s define the difference between ketosis and keto-acidosis and try to clarify the misinformation that is being spread around the blogosphere.

A ketone is a molecule the body produces from the breakdown of fat and some proteins (amino acids). There are specifically three types of ketones: beta-hydroxybutyric acid, acetoacetic acid and acetone. If ketosis was “bad,” then why would our bodies produce these molecules? They are not bad, and in fact, multiple studies show that the body is often more efficient and effective when it functions on ketones rather than glucose as its primary fuel source. The body can only supply a limited amount of sugar or glucose for fuel. If you talk to runners, marathoners or triathletes, they will tell you that after about 45-90 minutes of continuous endurance exercise the glucose supply runs out and they will experience what is termed a “bonk” (have a low-blood sugar or hypoglycemic episode). Unfortunately, our bodies can only store about 18-24 hours of glucose.

Metobolic Changes of Ketogenic Diet (American Journal of Physiology – Endocrinology and Metabolism Published 1 June 2007 Vol. 292 no. 6, E1724-E1739 DOI: 10.1152/ajpendo.00717.2006)

However, the body can store days upon days of fat in the form of triglyceride in the fat cells. Triglyceride is broken down into ketones. If glucose is the “unleaded” fuel, you can think of ketones as the “diesel fuel” that is easier to store and runs longer.

The average body functioning on ketones as the primary fuel will have a ketone level measured in the blood somewhere between 0.4 and 4 mmol/L. Because of a balance that is created by the use of ketones and a feedback mechanism that kicks in when the ketone level rises, the body will maintain a pH of around 7.4.

Ketoacidosis is dramatically different. If you are a type I diabetic, you don’t produce any insulin. The feedback mechanism regulating ketone use is broken and the ketone levels and triglyceride breakdown speeds up because the body can’t access glucose and can’t produce insulin. The ketone levels spike and the level can rise to > 25 mmol/L. In the presence of a high blood sugar and high ketone level, the acid level in the blood shifts to a pH of less than 7.3. This is referred to as metabolic acidosis and can be life threatening as the low pH shuts down the bodies’ enzymatic processes and a person becomes critically ill and without treatment, can die. (Kitabchi AE et al., Clinical features and diagnosis of diabetic ketoacidosis and hyperosmolar hyperglycemic state in adults. www.uptodate.com, May 2015.)

If you’re not a type I diabetic, you have nothing to worry about. Regardless of what the “ketogenic nay-sayers” blog about, your liver makes approximately 240g of glucose per day, this stimulates a basal release of insulin which keeps the pH in check. It’s also what keeps weight loss at a consistent pace of around 2-10 lbs per month.

If you are a type I diabetic, don’t fret. Carbohydrate restriction can still be used very effectively. It just takes some balancing and understanding of your individual metabolism. Talk to your physician and/or medical bariatrician about how to follow a carbohydrate restricted diet while using insulin.

What about all the other “adverse effects” the blogosphere and other so-called experts claim about ketogenic diets?

Let’s take them on one by one. Are you ready?

Gastrointestinal (GI) disturbances – Yes. Any time you change your diet you may experience diarrhea, constipation or gassiness. Most of the time, this is because you are either 1) not eating enough leafy greens (fiber) or 2) you’re using a supplement that contains an artificial sweetener. Most of the studies on ketogenic diets did not incorporate fiber and the studies used to make this point were on children who used a ketogenic fat supplement shake or liquid preparations containing these artificial sweeteners to make them palatable. If you have spoken to any bariatrician, they will tell you, the best way to follow a ketogenic diet is to eat real food. If you want to read about the anecdotal GI effects of sweeteners, read the comment section in Amazon about the Haribo Sugar Free Gummy Bears.

Oh, by the way, 65% of patients in my practice following ketogenic diet see improvement in gastroesophageal reflux (GERD) symptoms. (Austin GL, Thiny MT, Westman EC, Yancy WS Jr, Shaheen NJ. A very low carbohydrate diet improves gastroesophageal reflux and its symptoms: a pilot study. Dig Dis Sci 2006;51:1307–2.)

Hair Loss/Thinning – Really?! It is important to note that hair loss/thinning can occur with any form of weight loss (Novak MA, Meyer JS. Alopecia: Possible Causes and Treatments, Particularly in Captive Nonhuman Primates. Comparative Medicine. 2009;59(1):18-26.) This is especially true if you are restricting calories, which was occurring in a number of the ketogenic dietary studies previously published. You do not and should not need to “restrict calories” if you are following a ketogenic diet correctly, and in fact, most people take in more than 1800 calories on a ketogenic diet. (Shai I, et al., N Engl J Med, 2008; 359:229-241.)

Inflammation Risk – In every patient that I have placed on a ketogenic diet in the last 8 years, all inflammatory markers including CRP, Sedimentation Rate and Uric Acid have all decreased. Inflammation gets better on an appropriately formulated ketogenic diet. The older studies of ketogenic diets in children contain most of their fat from Omega-6 fatty acids from vegetable oil which will increase inflammation and oxidative stress, spike the cortisol levels and have the secondary effect of actually raising the triglycerides. (Simopoulos AP,The importance of the ratio of omega-6/omega-3 essential fatty acids, Biomed Pharmacother., 2002 Oct;56(8):365-79.)

Kidney Stones/Gout – These (Kidney Stones & Gout) are both commonly caused by spikes in uric acid. As noted above, I’ve seen multiple cases in my practice where a ketogenic diet lowers uric acid. Only a small clinical trial has been published in the literature (and it wasn’t truely ketogenic), but the results point to the potential for ketogenic diets to lower uric acid. (Dessein PH, Shipton EA, Stanwix AE, et al. Beneficial effects of weight loss associated with moderate calorie/carbohydrate restriction, and increased proportional intake of protein and unsaturated fat on serum urate and lipoprotein levels in gout: a pilot study. Ann Rheum Dis 2000; 59:539-543.) Ketogenic diets also have the capacity to lower the formation of calcium oxalate stones through a secondary mechanism I won’t go into here. Are these a risk? Only if you cheat on your carbohydrate restriction. So, I warn patients. Don’t cheat.

Muscle Cramps/Weakness – The process of weight loss occurs by burning fat into CO₂ and water. We breathe the CO₂out, but the water produced has to follow salts out through the kidneys. Hence, we lose salts. This can cause weakness and muscle cramps. The solution? Stop restricting salt on a low carbohydrate diet. We are the only mammal that restricts salt and we do it because low-fat diets cause us to retain water. Low carbohydrate diets do the opposite. Use sea salt or sip beef or chicken bouillon broth with your dinner. The use of yellow mustard also helps (the small amount of quinine in yellow mustard stops the cramping). If you have congestive heart failure, talk to your doctor about monitoring your salt intake in balance with your diuretic or water pill.

Hypoglycemia – If you read the ketogenic diet research, most of it was done on epileptic children. The diets called for a period of starvation, then the use of a ketogenic liquid based on the John’s Hopkin’s protocol. It is a well-known fact in medicine that starvation in children can frequently cause hypoglycemia, especially in children with other genetic or congenital defects leading to forms of epilepsy. In clinical practice, with ketogenic diet use in adults, hypoglycemia is rare.

Low Platelet Count (Thrombocytopenia) – Again, this was seen in the epileptic children who were placed into starvation first, then introduced a liquid fat replacement shake to stop intractable seizures. These liquids or shakes were often nutrient deficient in other essentials. Folic acid, B12 and copper deficiency can occur when not eating “real food.” Low platelet counts are rarely seen on ketogenic diets based around “real food.” Many children in the ketogenic studies had been on or were concomitantly on valproic acid for their seizures. Valproic acid is commonly known to cause thrombocytopenia (Barry-Kravis E et al, Bruising and the ketogenic diet: evidence for diet-induced changes in platelet function. Ann Neurol. 2001 Jan;49(1):98-103.; Kraut E, Easy Bruising, http://www.uptodate.com, May 2015.)

Impaired Concentration/Mood – A number of patients starting carbohydrate restriction will go through 2-4 weeks of carbohydrate withdrawal. This can be just as powerful as morphine withdrawal in some patients. Sugar is a drug and effects the same hedonic receptors that morphine does in the brain (Lustig, Robert H, Fructose: Metabolic, Hedonic, and Societal Parallels with Ethanon, Journal of the American Dietetic Association , Volume 110 , Issue 9 , 1307 – 1321.) Some patients will experience headache, tremor and decreased concentration while “withdrawing” off of starches and carbohydrates. Studies actually show that after a period of adaptation, cognitive function actually improves (Krikorian R, Shidler MD, Dangelo K, Couch SC, Benoit SC, Clegg DJ. Dietary ketosis enhances memory in mild cognitive impairment. Neurobiology of aging. 2012;33(2):425.e19-425.e27. doi:10.1016/j.neurobiolaging.2010.10.006.)

Metabolic Acidosis – As described above, this can occur in a type I diabetic, and metabolic acidosis has also been shown to occur in young children placed on severe carbohydrate and protein restriction, as was the case in some of the ketogenic dietary trials with epileptic patients. (Saxena VS, Nadkarni VV. Nonpharmacological treatment of epilepsy. Annals of Indian Academy of Neurology. 2011;14(3):148-152. doi:10.4103/0972-2327.85870.; Freeman, et al., The Ketogenic Diet: One Decade Later, Pediatrics March 2007; 119:3 535–543)

Osteoporosis/Osteopenia – If your ketogenic diet is “shake” or “meal replacement” based, you run the risk of mineral deficiency that could lead to Osteoporosis, however, if you are using real food, the opposite is true and most patients have improvement in their Vitamin D levels and bone density. (AG Christina Bergqvist, Joan I Schall, Virginia A Stallings, Babette S Zemel, Progressive bone mineral content loss in children with intractable epilepsy treated with the ketogenic dietAm J Clin Nutr December 2008 88: 1678–1684; doi:10.3945/ajcn.2008.26099)

Easy Bruising – This is usually due to inadequate protein supplementation as was the case in much of the ketogenic literature where protein levels were also restricted. (Kraut E, Easy Bruising, http://www.uptodate.com, May 2015.)

Infections/Sepsis/Pneumonia – These have not been issues in the 8 years I have been using ketogenic diets with my patients. These issues were seen in the John’s Hopkins protocol with children who had epilepsy and other congenital disorders placed on a diet low in protein and carbohydrate. (Saxena VS, Nadkarni VV. Nonpharmacological treatment of epilepsy. Annals of Indian Academy of Neurology. 2011;14(3):148-152. doi:10.4103/0972-2327.85870.)

Pancreatitis – Patients who are insulin resistant or have impaired fasting glucose commonly have high triglycerides. Elevation in triglycerides itself is a cause of pancreatitis. Ketogenic diets lower the triglycerides. However, if a patient has not been following their diet as directed, spikes in the triglycerides can occur placing the person at risk for pancreatitis.

Long QT Intervals/Heart Arrhythmias – The list of things causing Long QT intervals and abnormal heart rhythms is long and variable (Acquired Long QT Syndrome. Berul C et al. www.uptodate.com, May 2015). It is well know that starvation, rapid weight loss and liquid protein diets can cause a delay in the conduction signal in the heart. Anyone wishing to start any diet should have an electrocardiogram (EKG) through their doctor to ensure that the diet (of any type) doesn’t exacerbate a prolonged QT interval.

Three year weight loss and metabolic improvement in a patient on a Low-Carb / Ketogenic diet. Note: Patient admits to not following ketogenic diet during holidays from Nov 2013 – Feb 2014 (see the dramatic changes to the body when cheating happens)

Cardiomyopathy – Prolonged QT intervals have been associated with cardiomyopathy and the former can stimulate the later. Any diet that has the potential to prolong a QT interval has the potential to cause cardiomyopathy. Hence the need for regular EKG monitoring on any diet (Acquired Long QT Syndrome. Berul C et al. www.uptodate.com, May 2015).

Lipid/Cholesterol Changes – In the 8 years I have been applying ketogenic diets to patients, I have seen dramatic improvement in the triglycerides and HDL levels. The only time triglycerides rise over 100 is if the patient is using artificial sweeteners or is cheating on the carbohydrate restriction. Total cholesterol commonly rises, however, this is indicative of the fact that there is a shift in the LDL particle size and this affects the calculation of both total cholesterol and LDL-C. In light of this, most of my patients have dramatic improvement in triglycerides and small dense LDL particle number. I’ve included the common cholesterol changes I seen in my office as a few case reports to demonstrate the effectiveness of a ketogenic diet:

2 year ketogenic dietary labs and weight loss

Myocardial Infarction – It is interesting that one blogger includes this on the list of adverse reactions, however, when you actually read the study, the author of the paper make an “assumption” that there was potential for heart attack due to an elevated total cholesterol, however, a correlation was never made. Again, in the 8 years I have been using ketogenic diets, I have seen dramatic improvement in cholesterol profiles, inflammatory markers, atherosclerosis and carotid intimal studies (Shai I et al, Circulation 2010; 121:1200-1208).

Three year metabolic history of a Low-Carbohydrate / Ketogenic diet

Menstrual Irregularities / Amenorrhea – It is well known that any diet causing protein or other nutritional deficiency will affect the menstrual cycle first and growth second. The only time menstrual irregularities occur with a ketogenic or Low-Carb diet is when a patient is not taking in enough protein or is not eating real food. What amazes me is that a properly applied ketogenic diet causes normalization of the menstrual cycle, and in my practice, I’ve had a number of women successfully be able to conceive after making a ketogenic dietary change.

Death – All cases of death related to ketogenic diets have been documented in children while using liquid formulas for ketosis to treat epilepsy. These cases revealed the formation of a prolonged QT interval leading to cardiomyopathy due to deficiency in selenium. This has been solved by the addition of selenium to the ketogenic supplement. (Stewart WA et al., Acute pancreatitis causing death in a child on the ketogenic diet, J Child Neurol. 2001 Sep;16(9):682.; Bergqvist AG et al, Selenium deficiency associated with cardiomyopathy: A complication of the ketogenic diet. Epilepsia. 2003 Apr;44(4):618-20.; Kang HC et al., Early and lat onset complications of the ketogenic diet for intractable epilepsy, Epilepsia. 2004 Sep;45(9):1116-23.; Kang HC et al, Efficacy and Safety of the Ketogenic diet for intractable childhood epilepsy: Korean Multicentric Experience, Epilepsia. 2005 Feb;46(2):272-9.) This does not happen when the diet is based on the use of real food instead of supplementation and has not been seen in adults.

For more details on the nutrient content of a ketogenic diet, see the recent article by a friend of mine, Maria Emmerich. She’s been creating ketogenic diets for years and has a number of fantastic books my wife and I have been using in our home over the last nine years. She is one among many that can give you some direction on how to devise a healthy, real food based ketogenic diet. See the page on my website here that will give you some direction in formulating your Ketogenic Lifestyle.

Nally Family Low-Carb / Ketogenic Cheese Cake

So, to celebrate Mother’s Day, today, with my family, I am going to indulge in some Low-Carb / Ketogenic Cheese Cake!! Happy Mother’s Day, to all of you and especially to all you mothers out there making a healthy difference in the lives of your families! (You can find the recipe for this delicious cheese cake here)

In the words of Sir William Ostler, “If it were not for the great variability among individuals, medicine might well be a science and not an art.”

March 27, 2015

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?

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.

December 12, 2014

Tiffini’s Fat Bombs

There are a number of recipes for “Fat Bombs” on the internet, but this one is my wife’s version. These have been a lifesaver for starting and maintaining a Low-Carbohydrate or Ketogenic diet over the last few years. They are fantastic mid-meal or anytime Low-Carb snacks, full of satiating fat, that really help during the holidays. I mentioned Fat Bombs to my patients in my Low-Carb Group Visit Class today and I promised to post them here:

Fat Bombs:

1 stick of real Butter softened

1 cup Coconut Oil

1/2-2/3 cup Erythritol

1 tsp liquid Stevia

1/3 cup Cocoa Powder

1 cup Peanut Butter or Almond Butter

2 cups chopped Macadamia Nuts or slivered Almonds

1-2 cups of Coconut

Mix together and place 1-2 table spoon sized scoops in small muffin tin or on wax paper. Must be kept refrigerated to remain firm.

Enjoy!!

September 6, 2014

Hypertension and Insulin Resistance

Hypertension (elevated blood pressure) is one of the triad symptoms of metabolic syndrome. I see this to some degree a very large majority of the people seen in my office. Many people are so used to having borderline or elevated blood pressure, and not successfully controlling it through caloric restriction, they are told it is a “genetic problem,” placed on blood pressure medication and sent on their way. The problem is that most of these people will have a progressive elevation in blood pressure over time and these medications are continually raised until the person is on four or five different blood pressure medications at maximal doses. Again, their genetics are blamed and that is the end of it. Or is it?!

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 begin to back down their medications, they would experience symptoms of dizziness, light-headedness, headache and a few patient’s nearly passing out. 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) constricts the blood vessels and raises blood pressure. Yes, that donut you just ate raised your blood pressure for the next 12 hours.

All of this can be seen in the really complex diagram found in Dr. Lustig’s 2010 article:

Lustig R. J Am Diet Assoc. 2010

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.

Second, limit your overall intake of other sources of carbohydrates including any type of bread, rice, pasta, tortilla, potato, corn and carrots. Realize that fruit is fructose, and when taken with other forms of glucose can have the same effect as table sugar.

Third, if you are taking blood pressure medications, see your doctor about close monitoring of your blood pressure as it can drop within 1-2 weeks of making these dietary changes.

August 2, 2014

Fat Phobia . . . The Religion

“You want me to eat WHAT?! But that’s . . . ,it’s . . . FAT, really?”

” Yes, it is.”

Every day, instruction to my patients is initially seen as Food Pyramid heresy and My Plate iconoclasm. Yes, I want you to flip the Food Pyramid on its head, and push everything off My Plate and fill it with fat. . . Really. . . Yes, I do.

I was counseled by many school professors over the years that there are two things you should avoid talking about: Religion & Politics. The ketogenic or low carbohydrate dietary conversation involves both. “Fat Phobia” is a Religion. We have demonized fat and sainted the treadmill. You see, fat got a bad wrap when the bomb calorimeter was invented. We realized that there was twice as much energy found in fat that there was in carbohydrate or protein. Early nutritionists, understanding that heat is a form of energy, and realizing that energy is conserved, found that food substrates contain a set amount of energy that can be measured in a closed environment. Naturally, the Law of Thermodynamics got applied to lend understanding in how people gain or loose weight. We coined the term “you are what you eat” based upon our understanding of the Laws of Thermodynamics. The calorie became “king.”

1 gram of carbohydrate = 4 kcal
1 gram of protein = 4 kcal
1 gram of fat = 9 kcal

For the last sixty years (an entire generation of humans) we have based our diet around the calorimetry of food and have labeled them as good or bad based upon calories. To loose weight, we are taught, you either have to eat food containing fewer calories (fat has the most calories per volume so it must be bad!) or burn it off faster than you take it in (did you go exercise at that new gym next door), right? Wrong.

First, you and I are not bomb calorimeters. We are not closed systems. We harbor variable levels of symbiotic bacteria (these also burn fuel at variable rates) and our body temperatures fluctuate to regulate other enzymatic and hormonal processes.

Second, bomb calorimetery functions on the premise that volumes are also held at a constant. Human volume and density change daily. Simple chemistry tells us that volume = mass / density. The average human mass fluctuates by 5lbs every day and our density changes based upon our hydration status (the amount of water we drink). Because these two variables are not constant in a human being, it is impossible to correctly apply the Laws of Thermodynamics to the human body and accurately predict weight gain or loss.

Third, hormones! (Anyone married to a pregnant female understands that nothing is as it seems when hormones are involved.) We have a plethora of hormones that change the rate in which fuels are burned or stored in the human body. Our GI flora (symbiotic bacteria in the human gastrointestinal tract) are also affected by hormones and do not have set rates of fuel use or breakdown. What this means is that you and I process food at different rates and derive different levels of energy and fuel from the same donut. Genetics plays a leading role in how these hormones are used and turned on and off. Fat is burned or stored in the body based on a hormonal mechanism I described in a previous post you can read here.

Asking patients to reduce carbohydrate intake to less than 20 grams per day and increasing fat intake to up to 70% of total caloric intake is essentially 20th century nutritional apostasy.

The dietary concepts from the Food Pyramid and My Plate have been embraced by our country for over sixty years. Changing our views on these as a country will be for many like changing religions. For those of us “with eyes to see and ears to hear” our work is cut out for us.

May 31, 2014

Ketogenic Diet Reduces Diabetic Nephropathy

A common problem that arises in patients with diabetes is that of kidney disease or “nephropathy.” Nephropathy is defined as damage to or disease of the filtering system of the kidney. In diabetic patients, they commonly begin to loose the ability to adequately filter and retain microscopic protein needed in the body. As the blood sugar and insulin levels progressively rise over time, damage to the delicate filtering system of the kidneys occur.
Very impressive results revealing improved kidney function were found in both Type I and Type II diabetic mice placed on a low carbohydrate, or ketogenic, diet in just and 8 week period of time. The nephropathy (reduced passage of protein through the kidneys) was completely reversed in all the mice. This is the first in what I suspect will be a series of articles showing that ketogenic diets have significant effect on reversal of age related and diabetic tissue damage. See the article here.