I started my Ketogenic Mediterranean Diet on September 1, 2009. After two months, I stopped compulsive record-keeping and food measurement and made a few other intentional tweaks: fish five times a week instead of seven miminum, more nuts (often two ounces a day—I like nuts and they’re convenient), less salad, more dark chocolate. Otherwise the last four months have been similar to the initial two months of strict KMD. My daily digestible carbohydrate intake has probably crept up to 40 g compared to 20-25 g on the strict KMD—this is still considered very low-carb.
Accomplishments
Starting weight was 170 pounds (77.3 kg) on September 1. After two months—8.6 weeks—my weight clearly stabilized at 155 lb (70.5 kg). I lost the 15 lb (6.8 kg) over the first six weeks then just hovered around 155 lb. So average weekly weight loss over the six weeks was 2.5 pounds. Also lost a couple inches (5 cm) off my waist.
For the last four months—November through February—I’ve been eating the aforementioned liberalized KMD. Weight has stayed around 155-157 lb (71 kg). No calorie counting. I eat as much as I want, except for carbs. The experience of the first two months taught me how to eat 20-25 g of carbs in a day; it’s the gauge by which I estimate I’m eating 40 g daily now.
Has It Been Easy?
Yeah, relatively easy. Two other adults in my house are also eating low-carb, which definitely helps. Blogging here also helps me maintain compliance. I promised myself to report everything—the good, the bad, and the ugly—honestly. Accountability is important.
Staying with the program may be easier for me than for others because I am heavily invested in it, psychologically and time-wise.
It’s also been helpful for me to participate at two low-carb online communities: LowCarbFriends and Active Low-Carber Forums. We support each other. Thanks, guys.
I took diet holidays twice, for three days at both Thanksgiving and Christmas. Gained three to five pounds (1.8 kg) each time on high-carb eating, but lost it over the next week by returning to the strict KMD.
Any Surprises?
Induction flu. I’d never heard of it before. Occurs typically on days 2–5 of very low-carb dieting: achiness and fatigue. Others also experience headaches and dizziness, and it may last 1–2 weeks.
Rapid weight gain during my diet holidays (aka cheat days). I was not gorging. I figure the weight was mostly new glycogen in liver and muscle. And water.
Eating fish more than once a day is a lot of fish! Quickly boring, even unappetizing. But that’s just me. I need to be a more creative. Most of my fish lately has been canned tuna.
Assuming that the Daily Values of various nutrients recommended by the U.S. Food and Drug Administration are valid, the KMD foods come up short in many vitamins and minerals. I bet this is an issue (a problem?) with many, if not most, very low-carb diets if supplements aren’t used. Those Daily Values are debatable, of course. For instance, Gary Taubes argues that you don’t need much vitamin C if eating few carbs. My nocturnal leg cramps and constipation were proof enough for me that I needed at least some supplements. The recommended KMD supplements remedy the DailyValue shortfall in vitamins and minerals. Dr. Richard K. Bernstein has a 30-gram carbohydrate diet for his diabetic patients and himself, as outlined in his Diabetes Solution book: no supplements are required.
As time passes, I worry less about getting enough of various micronutrients. I feel fine. I’m still taking the recommended KMD supplements (5 pills a day) plus sugar-free Metamucil.
I never had hunger that I couldn’t satisfy within the guidelines of the diet.
No major trouble with cravings or longing for carbs. I’ve gone six months now without whole grain bread, oatmeal, pizza, and pasta—very unusual for me. I’d be OK never eating them again. What I do miss are sweet, often fat-laced, carbohydrates: pie, cookies, cinnamon rolls, candy bars, cake, ice cream. I doubt that desire will ever disappear, although it does for some who eat very low-carb.
I counted calories only during the first two months of this experiment. Remember, fats and proteins are unlimited. Nevertheless, I ate fewer calories than my baseline intake. This calorie reduction is a well-documented effect of very low-carb diets. Fats and proteins are more satiating than carbohydrates. It’s possible I’ve limited total calories subconsciously.
[An interesting experiment would be to try to gain weight by over-eating fats and proteins while keeping total digestible carbs under 30 g/day. Has it been done already?]
What’s Next?
I’d like to answer some intriguing questions.
Why did my weight loss stop where it did, at 155 lb (70.5 kg)?
If I’d started the KMD at 270 lb (123 kg) instead of 170 lb (77.3 kg), would my weight loss have stopped at 255 lb (116 kg), 210 lb (95.5 kg) or 155 lb (70.5 kg)?
Will two people, 300 lb each (136 kg), end up at the same final weight when following the program religiously? Probably not, but why not?
Six months ago, I believed many scientific studies supported the idea that a higher intake of carbohydrates is healthier, long-term, than the very low-carb Ketogenic Mediterranean Diet and other very low-carb diets. Studies seemed to support higher carbohydrate intake in the form of traditional fruits, vegetables, legumes, and whole grains. After reviewing the scientific literature over the last few months, I’m not so sure that higher carb consumption is necessary or beneficial for long-term health and longevity. The evidence is weak. Nearly all the pertinent studies are observational or epidemiologic—not the most rigorous science.
On the other hand, I still can’t help feeling that the recommended eating styles of people like Monica Reinagel, Darya Pino, and Holly Hickman may be healthier than the KMD over the long run, at least for people free of diabetes and prediabetes. What features unify those three? Food that is minimally processed, fresh, locally produced when able, including a variety of fruits, vegetables, nuts, whole grains, and legumes.
It seems that the human body is marvelously designed to survive, even thrive, with multiple ways of eating—but not all ways.
The strongest evidence for higher carb consumption supports whole grains as a preventative for heart disease (coronary artery disease). But the effect is modest.
The argument against higher carb consumption is simple for people with diabetes and prediabetes: carbs raise blood sugar levels, sometimes to an unhealthy degree.
I don’t see much role for highly processed, refined carbohydrates except as a cheap source of energy (calories).
What’s next for me is to formalize an opinion on which carbs, if any, and in what amount, to add back into the diet of those who have lost weight with the Ketogenic Mediterranean Diet. The answer will probably be different for two groups:
- those who have diabetes, prediabetes, or metabolic syndrome
- healthy people who just need to control weight
The goal is to maximize health and longevity without tipping over into excessive carb intake that leads to overweight and obesity with associated illnesses.
The traditional Mediterranean diet—long associated with health and longevity—is rich in carbohydrates. The Ketogenic Mediterranean Diet—much lower in carbs—has great potential to help with loss of excess weight and control of blood sugar levels. Does the KMD incorporate enough of the healthy components of the Mediterranean diet? We may never know for sure.
Diabetic Mediterranean Diet 
Interesting. I had a couple of thoughts that were stimulated by your summary.
1 – I wonder what happens when one separates out fruit vs grains. So if you were eat your KMD but added fruit, it really wouldn’t be ketogenic but I’m guessing it’d still be fewer carbs than a regular diet. Would the phytonutrients provide more of a benefit?
2 – Any info on the Warburg effect?
Hi, Isaac.
Many people stay ketogenic (as measured by urine ketostix) if they keep digestible carbs under 50 g/day. It varies by person and total caloric intake.
My sense is that, ounce for ounce, grain products have much more carbohydrate than fruits.
The typical American way of eating provides 250-300 grams of carbohydrate daily.
It’s a tough call, but I think fruits provide more healthy phytonutrients than grains. I’m open to arguments to the contrary. Lot’s of “what ifs” and “it depends.”
-Steve
I’m not familiar with the Warburg effect.
I find this post really interesting. Since I’m from Spain, which is suppossed to be one of those Mediterranean diet countries, at least in the past, I regularly eat lots of carbohydrates. I’m now trying to reduce both sugar and carbs intake, to see if I can lose weight (from 79Kg to 75 or less). However I find extremly difficult to avoid carbs, especially for breakfast. I also find very difficult to avoid fruits (not so sure because everyone says that you MUST eat them at least 5 pieces per day). How did you handle that in your experiment? What did you use to replace fruits, legumes, grains, etc…?
Hello, Aitor.
My usual breakfast has included eggs and a meat such as bacon, sausage, or ham. As much as I want. Sometimes with limited cheese. Often pico de gallo on the eggs.
Except for olives, avocados, and tomatoes, I had cut out most fruits. Also stopped eating legumes (except peanuts) and grains. That’s why I developed a tendency to . . . ahem . . . constipation. Metamucil fixed that. Nevertheless, I ate about 200 grams a day of vegetables, which is quite a bit. It’s also at the low end of the range for fruits and vegetables recommended by Dr. David Heber, author of “What Color is Your Diet.” I blogged about Dr. Heber’s recommendations here in the last two weeks.
So, I was eating mostly meats, poultry, FISH, olive oil, eggs, 3 ounces (100 g) cheese daily, and vegetables 200 g daily. And a glass of wine daily at night if my workday at the hospital were over.
I’m glad to hear from a Spaniard. The University of Navarra in Cordoba is doing great work investigating the Mediterranean diet.
-Steve
hi,
to be honest, i found your writing/reasoning weird.
you went on KMD because there is no scientific evidence to support carbs in form of whole grains lead to a healthier life (one might argue how to measure that anyway), meaning there is evidence for KMD?
at the end you mention that lifestyles a la monica reinagel or darya pino might actually be better than KMD, without giving any reasoning whatsoever.
as for health, is there really any proof doctors, at the moment, have the necessary diagnostic skills to evaluate one’s health? when i read papers from the field of medicine or nutrition (i have no education in either of those two fields) i am left wondering how they actually measure success in terms of health. it isn’t fine scaled enough to do so IMO.
Howdy, thomas. Thanks for visiting and commenting.
The usual evidence in favor of carbohydrate consumption is from observational studies that look at large populations over time, noting health outcomes, and analyzing what the healthiest peope ate. “Healthiest” might be defined as who died and who didn’t. That’s pretty easy to determine. Or in terms of a specific disease such as macular degeneration or heart attacks or cancer. The epidmiologists find associations in the mass of analyzed data. Overall dietary patterns, such as the Mediterranean diet, the DASH diet, and the so-called “prudent diet” often come out ahead in terms of health. There may be a healthy synergy among the nutrients that can’t be attributed to specific components such as legumes, whole grains, vegetables, fruits, etc. But I consider these sorts of studies to be relatively “soft science.”
Here’s an example of “hard science.” Take 20,000 adults, very similar to each other, who never eat whole grains. Somehow force half of them to eat two servings a day of whole grains while the other half continues to avoid them. Keep all other conditions the same. Follow all 20,000 folks for ten years and note all differences in health outcomes. All major health outcomes, including death. Then you could begin to make some firm conclusions. But you can imagine the difficulty in doing such a study in free-living humans. It’s a lot easier to study lab rats.
That’s why we have to fall back on observational studies so often.
-Steve
howdy steve, thanks for answering 😉
but isn’t this the problem? healthiest means to have ie. a mental performance that is the best possible. not being moody etc. all those mental things are hardly ever included in ‘healthiest’. but if you ask someone they might actually be a lot more important than having cancer at the age of 70 or dying earlier.
when you have diabetes, chances are, you haven’t been healthy (or in other words: the best possible you) for months/years before you have been diagnosed.
if you keep all other conditions the same, you are right. but that includes everything. from radiation to pollution to activity to stress to overall happiness (so anyone who gets a divorce should be eliminated from the study etc).
and no doubt about lab rats, just how useful are they?
-thomas
Two things. One, re all that canned tuna, hope it’s a good source! Between the toxins that tuna ingests and the BPA that may be in the cans, I’m slightly concerned. I get canned salmon and tuna from Vital Choice, but I’m trying to keep it to 2-3 servings a week.
Two, I am so with you on the question of grains and health. Kurt Harris and Mark Sisson make a good case for why grains are problematic, but I’m hoping that a Stephen Guyanot (avoid wheat) and/or WAPF (only consume sprouted, soaked, or fermented grains) may be suitable. And I say this as someone not starting from a position of health. We’ll see!
For now, I’m planning on avoiding grains. And I’m also thinking of cycling different levels of carbs rather than staying ketogenic. Seems to provide more flexibility.
Hi, Beth. I’m keeping my eye on the BPA-canned goods story, currently in its infancy.
In over two decades of medical practice, I’ve never run across a case of mercury or dioxin poisining from fish consumption. I do wonder sometimes how much it would cost me to have a lab run a mercury level on me.
-Steve
Interesting blog!
Fruits are delicious and offer great benefits, but there’s ABSOLUTELY nothing in fruits that you can’t get from non-starchy vegetables…except fructose. So fruits are certainly not necessary.
I love peanuts but like most legumes they probably are inflammatory..alas, I try to limit them and steer more toward almonds and walnuts.
Randy, thanks for you idea on legumes and inflammation. Looks like I’ve got some more research to do!
-Steve
I’ve been on a low-carb diet for the last 18 months, and the craving for any sweet foods are gone. In fact, my sense of sweet has been amplified. Most foods with any sugar, with the exception of berries, are now “too sweet”. I also experience adverse reactions to eating even a moderate amount of sugar. I get flushed and my blood pressure skyrockets. If I eat even a moderate amount of sugar, I actually feel ill.
I also eat only fresh or frozen fish. The processing steps for canned fish probably result in oxidation of the polyunsaturated fats, although I haven’t found any data to confirm or refute this.
I also take supplements with the exception of vitamin C and alpha-tocopherol. My secondary goal is good health, but my primary is more immediate. Every male in my ancestral tree with the exception of myself and one other, has experienced a stroke or heart attack before age 50.
I’ve also kept a nutritional database quantifying my food intake. Eating primarily whole foods provides roughly 4,000mg potassium a day and only 2,000 sodium. I actually had to add a little sea salt to my diet because my blood pressure dropped too low on a low carb diet.
Hi, Ed T-
Thanks for contributing your interesting story. A family history like yours would certainly motivate me to do all I could to avoid that fate.
-Steve
Hi Dr. Steve,
I have an interesting question for you. How would one know if they have metabolic syndrome or prediabetes? Most doctors do not test for that sort of thing.
Another related question: if you are overweight, then do you *definitely* have metabolic syndrome (at the very least) or can you be overweight without having it? I always got the impression that overweight = metabolic syndrome, but I’m not sure…..
Thanks.
Hi, Annika-
Good to hear from you. Most busy primary care doctors don’t bother to diagnose metabolic syndrome. You can diagnose yourself if you know your blood pressure, HDL cholesterol, fasting blood sugar, and triglyceride level. The diagnostic criteria are at one of my other blogs:
http://advancedmediterraneandiet.com/blog/?p=103
Overweight and obesity are not the same as metabolic syndrome. You can have one without the other even though most people with metabolic syndrome are at least overweight.
-Steve
Nice article!
I lost 56 pounds in about six months on a low-carbohydrate diet a couple of years ago. For the most part I lost nearly 2 pounds a week with minimal effort, and hardly ever went to the gym (which is in stark contrast to the low-fat diets I tried over the years, where going to the gym 5 days a week hardly made me budge).
A couple of comments:
1) I used to eat a lot of canned tuna, probably 5 times a week as well. Most of the time I covered mine in normal mayo (not the low-fat/high-sugar stuff). You point out that it’s fish, which it technically is. But most canned tuna is water packed, not oil packed, and is missing most of the essential oils that most people associate with fish. I’d be interested to see what would happen if you added more fresh fish to your diet.
2) You said that your diet is ketogenic, and it looks like it probably is. But without testing using ketostix or the likes, how did you know for sure? Many people consume a lot more carbs than the think, especially in the form of creams for coffee, sweeteners, and condiments. This is a common probably for many people in the forums.
3) I personally found that a low-carb diet seemed to lose it’s effectiveness over time. After losing that weight initially, I found it harder and harder to keep off, almost like there was some feedback mechanism at work.
Duane-
Thanks for your comments.
I notice that the new Atkins book by Westman, Phinney, and Volek does not mention urine ketone testing at all.
There are indeed many carbs to watch out for! I had to give up my Starbuck’s grande lattes and milk in my coffee.
-Steve
What is the current state of knowledge about effects of ketosis (esp. prolonged ketosis) on muscle mass? Sorry if that’s off topic. I’ve been digging around and can’t seem to find anything other than opinions.
Also, regarding comment “there’s ABSOLUTELY nothing in fruits that you can’t get from non-starchy vegetables…except fructose” – er, that’s a pretty bold claim, friend. I don’t think we know enough about phytonutrients to say that (what did we know about antioxidants a decade ago?) I should think the sorry science behind the saturated fat – heart disease linkage, etc, etc is reminder enough to avoid blanket proclamations that are actually beyond our current ken.
Mediterranean diet is good for health health while low carb diet benefit our health through weight loss. You can actually combine this two diet by modifying the Mediterranean diet into a low carb version.
I was diagnosed with Type II diabetes three years ago. By restricting my diet to 100-130 grams of carbohydrates a day, eating a lot of fiber and protein, and exercising vigorously for at least one hour a day, I’ve remained well out of the diabetic range on HA1c tests and haven’t needed medication. The regimen has had other beneficial effects as well — for example, lowering cholesterol levels. I’d recommend this approach to others with high but manageable blood sugar levels, with their doctors’ OK.
MyDiabetesCure-
Good to hear from you. 100 grams of carb daily gives you a bit more flexibility compared to those eating 20 grams. I’m guessing you have more residual beta cell function (and insulin output) than some other folks with T2DM, or you improved your insulin resistance.
Great job taking control of your condition! Diabetes is one of those diseases in which you can’t just depend on your doctor to do it all.
Pretty good posting here,I never thought about that I will catch any information like that ,but your post really help me.Awesome things are sharing here.I like your post ,Now I am waiting for your next post.So keep writing.
I really appreciate the KMD and have been on it –in my fashion– for maybe 10 months. After being diagnosed with Diabetes II 18 months ago I get to monitor myself at close quarters.
I don’t take a vitamin supplement but I do take daily high dose fish oil mainly for pain relief from Fibromyalgia. After dealing with a weight loss plateau I now stay off all grains and find that I cannot tolerate dense carb vegetables nor legumes. I eat them and my blood sugar will at least rise 1-2 mmol.
The problem with low carb eating is the ready substitution of meat to make up for the caloric shortfall. I try to keep my meat consumption down in line with traditional Cretan cuisine and like them I eat a lot of olive oil. (The Cretan average consumption — under their Mediterranean diet — is 22 Kgm of olive oil per year per person). I love the stuff.
Induction caused an attack of gout and when I shifted my carb intake down further I got another dose of gout. So I’m a high Uric acid type with a family history of gout.
So be prepared. Diet changes are always a precursor for an optional gout attack.(if you are unlucky).
I tend towards firm stools now and may need to work up some means to increase my dietary ruffage as my daily salad intake isn’t enough. I see where Steve takes Metamurcil….
After lossing a kilogram a month ( 10 kgm over a year )I hit a plateau but am now losing weight after cutting back on what was a daily serve of high carb — bread or Basmati rice.
I don’t suffer from hunger pains; I love the culinary challenges and excitement of generating and discovering new meals under this regime. In that quest I am much taken with the foods of Sicily and Spain although I’m proficient across the menus of the Arab world.
Of late I’ve been eating olives almost daily and have upped my cheese intake and have always consumed Greek style yogurt. I cook with yogurt (eg: curries) and use it as a base for desserts (eg: berries and yogurt). I also use cream such as in au gratins; and en route have learnt to respect the humble pumpkin and cauliflower (which almost substitutes for rice). I’d like to eat sweet potatoes and legumes but they blow up my blood sugar readings and are maybe too carb dense for me. My snack foods are nuts — peanuts in their shell and almonds. I also like preserved meats…as a treat.
I drink two glasses of wine per day.
My blood workup is improving but it is too early to tell how much this diet is driving these results. I’m trying to deal with fluid retention issues but I doubt that this diet as yet has impacted on that issue for me.
My main goal — now that my blood sugars are stable — is to lose more weight and I expect i can at least lose another 5-6 kgm under this regime. I am physically active and exercise but this does not impact on my weight at all (as Gary Taubes points out in his books). It never has.
Am I suffering for my commitment? No bread, no potatoes, no sugar…? No I’m not. I love this food but am really challenged if I have to eat away from home.Even with family and friends it is so hard to explain what I’m not eating and why. So away from home my carb intake goes up.
I began this journey by dropping my carb intake from something over 200-300 grams of carbohydrate a day to something around 110-120 gms. I do better lower than this and would think I’m now eating maybe 50 grams or less on average per day. Once you exclude the high carb stuff thats’ easy to do.
Low carb eating has changed my life and Steve Parker’s dietary template has given me something to format my daily menus around as well as a series of clear perpectives to strive for.
I’ve eaten “Mediterranean’ for decades but always tending towards the high the carb scale — pasta, couscous, rice, bread etc — and followed a Glycemic Index dietary approach for years. But really that was insufficient to impact on my health and with ignorant doctors advising me I sailed through “Pre-Diabetes” to Diabetes II quicker than it is fair (esp with family history of Diabetes). If I had known then what I know now — going back a few years — my health would be much better.
The GI stuff trained me of course to respect the crab I put in my mouth but I think GI eating is a false god.
So listen up peoples: consider going down this route.
Dave, many thanks for sharing your experience.
I’m sorry to hear about your gout flare. One of these days I need to do a comprehensive post about gout. There’s still much that even expert physicians just don’t know about it, creating a void filled with mis-information.
-Steve
Well thats’ a conundrum aint it? While Gary Taubes offers a missing chapter on gout relative to low carb consumption
http://www.fourhourworkweek.com/blog/2009/10/05/gout/
I’m thinking that despite your own warnings — eg: don’t do this diet with high uric acid levels — I’m going to proceed as I have this past year or so
What choice have I? The fact is that Gout, obesity and Diabetes are part of the same spectrum. They are so often married. To then revert to higher carbs only raises my blood sugar. To NOT eat low carb means I keep the weight on. I’m hoping that my outbreak is induction induced and even if I have to take Allopurinol thats’ OK. My mother does and my dead diabetic dad did too.
So I proceed down this path.My one moderator is to perhaps replace sme meats with dairy….
Nonetheless, I have had many more gout attacks this past year than previously these last 10 . What confused me is that I thought they were injuries resulting from my exercise activities. I have had high uric acid levels recorded since 1985 so the chickens come home to roost. So I’m a special case, I need to point out.
But since I am now on Allopurinol lets’ see what happens…
Currently reading: Goodreads | Why Some Like It Hot: Food, Genes, and Cultural Diversity by Gary Paul Nabhan which has an interesting chapter on the Cretan Diet. Esp re Olive Oli.
i have vascullitis and am currently on 5 mg. of prednisone a day. I took my blood sugar two hours after eating today and it was 208. took it another hour later and it was 180. /am I at risk of diabetis?
Sorry for the delay in my response, jo anne. I’ve been extremely busy at the hospital lately. Our winter visitors to Arizona will be leaving for home in the next month, so it will slow down.
Yes, you’re at risk for diabetes. You may have it already. You’re on a very low dose of prednisone, so it may or may not be contributing to the high blood sugars. High-dose prednisone, say 30-80 mg/day, often causes elevated blood sugars into the diabetic range. I see many folks who have high blood sugars while taking prednisone, with return to normal sugars when they’re able to stop the prednisone. I don’t label those people as diabetics, although some might use the term “iatrogenic diabetes.” Talk to your doctor about these issues soon.
“What’s next for me is to formalize an opinion on which carbs, if any, and in what amount, to add back into the diet of those who have lost weight with the Ketogenic Mediterranean Diet. The answer will probably be different for two groups:”
Hi there
This has been my biggest consern with keeping weight off once you lost it and to “add back”. If I had followed the Ketogenic Mediterranean Diet and reached my goal weight, what eating plan/diet will be the best to reintroduce food again for example grains/fruit/yougurt without a relaps?
Hi, Eloise.
I think I may have come to a conclusion and answered the question at my Low-Carb Mediterranean Diet page.
-Steve