Category Archives: ketogenic diet
Men’s Fitness has an article extolling the virtues of ketogenic diets, particularly as they relate to athletic performance. Sadly, the piece doesn’t mention my Ketogenic Mediterranean Diet, which is incorporated into The Advance Mediterranean Diet (2nd ed.) and Conquer Diabetes and Prediabetes.
The article focuses on Professor Timothy Noakes (who also has an M.D. degree. Some quotes:
“Noakes’s war on sugar goes back a generation, to when his father developed type-2 diabetes. Type-2 is a disease in which the body gradually loses its ability to regulate blood sugar through the production of the hormone insulin. It’s linked to genetics, but also to diet—particularly sugar and refined carbs—as well as obesity and inactivity. Diabetes experts estimate that the disease speeds up the aging process by roughly a third, damaging the body from the inside out. Too much blood sugar slowly destroys blood vessels, with results ranging from mild—early wrinkling of skin—to catastrophic: heart disease, blindness, stroke, amputations due to poor circulation, and even Alzheimer’s disease (more on that later).
Noakes’ father eventually died from type-2, but because Noakes himself followed a low-fat diet, exercised regularly (he’s run upward of 70 marathons, as well as a handful of ultras), and didn’t smoke, he figured he’d be spared. To be sure, as he got older he put on some weight, and his energy sagged, but he was in good shape.
Regardless, in 2010, Noakes was diagnosed with type-2 diabetes. Though he didn’t know it yet, a lifetime of well-intentioned carbo- loading for his athletic endeavors had set him up for a fall.”
I got an email a few days ago from a blog reader, J.H. (I won’t give his name because I didn’t ask permission to publish his letter):
Dr. Parker — I’m a 65 year old male who has battled insulin resistance and pre-diabetes for many years. About 15 months ago I started pursuing a very low carb (20 grams per day) ketogenic diet, and my health has improved significantly. I’ve lost about 35 lbs (down from 265), and I have not found it difficult at all to stay on this regimen. You mentioned in an article (https://diabeticmediterraneandiet.com/ketogenic-mediterranean-diet/) that you don’t believe people can stay with it for more than 6 months and that most people can only last about two weeks. With all due respect, hogwash! I was fortunate enough to become a patient of Eric Westman at Duke, and he does an excellent job of teaching the ketogenic diet to his patients. Any overweight person should give it great consideration, and it’s just not that hard to follow.
Best regards, J.H.
My response was: “Congrats on a job well done! I wish all my patients had your discipline and commitment.”
I have great respect for Dr. Westman. He’s the c0-author of The New Atkins for a New You. I reviewed it in 2010. No clinical studies have compared the effectiveness of Dr. Westman’s diet to my Ketogenic Mediterranean Diet, which attempts to lasso the health benefits of the time-honored traditional Mediterranean diet while helping folks lose weight. The Ketogenic Mediterranean Diet is a key component of Conquer Diabetes and Prediabetes.
PS: You don’t have to know what ketogenic means to benefit from ketosis.
PPS: I have a non-diabetic version of the Ketogenic Mediterranean Diet for otherwise healthy folks who just need to lose a boatload of weight.
Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.
This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.
This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.) The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.
Here’s the program:
- 20 days of a very-low-carb ketogenic diet, then
- 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
- 4 months of a normal caloric Mediterranean diet, then
- repeat #1 and #2, then
- 6 months of a normal caloric Mediterranean diet
In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).
I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.
After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.
Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.
What Did They Find?
Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).
Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.
Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).
Liver and kidney function tests didn’t change.
The authors didn’t give explanations for the drop-outs.
Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned to their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”
A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.
However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.
Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.
I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!
There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.
I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).
How much of the success of this protocol is due to the herbal extracts and TISANOREICA? I have no idea.
The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).
The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved by a variety of diets.
The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.
The authors write:
The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.
I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.
Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205
I just finished reading The Low Carb Dietitian’s Guide to Health and Beauty, written by Franziska Spritzler, RD, CDE, and published in January 2015. CDE, but the way, means Certified Diabetes Educator. Per Amazon’s rating system, I give it five stars (I love it). It’s not written specifically for women with diabetes, but the included recipes are quite consistent with a healthy diabetic diet. Since the author provides the carbohydrate grams with her recipes, you can use them with my Low-Carb Mediterranean Diet and Ketogenic Mediterranean Diet.
* * *
This valuable addition to the low-carb literature is unique: No other book covers the beauty and health aspects of low-carb eating specifically in women.
I’m a strong proponent of carbohydrate-restricted eating for weight management and cure or control of certain medical conditions. The great advantages of low-carbing for weight loss are 1) suppression of hunger, and 2) proven greater efficacy compared to other types of dieting. Nevertheless, I wasn’t aware that this way of eating also had potential benefits in terms of beauty maintenance or improvement. The author persuasively makes that case in this ground-breaking book.
Just because she has RD (registered dietitian) behind her name doesn’t mean you just have to take her word for it. Franziska gives us references to the scientific literature if you want to check it out yourself.
The author focuses on health and beauty; the weight loss happens naturally with low-carb eating. That’s a helpful “side effect” since 2/3 of women in the U.S. are overweight or obese.
She covers all the basics of low-carb eating, including the rationale, potential side effects and how to prevent or deal with them, the science of “good fats,” the importance of plant-derived foods and fiber, info on artificial sweeteners, and management of weight-loss stalls.
Then Franziska does something else unique and very helpful. She offers three different eating plans along with a simple test to help determine which is the best for you. The options are 1) low-carbohydrate diet, 2) high-fiber, moderate saturated fat, low-carb diet, and 3) intermittent fasting low-carb diet with weekly treat meal. You can dig right in with a week’s worth of easy meals made from readily available ingredients.
It was interesting for me to learn that the author ate vegan-style and then pescetarian for awhile. In 2011 she was eating the usual doctor-recommended “healthy” low-fat high-fiber diet when life insurance blood work indicated she had prediabetes. So she cut her daily dietary carbs from 150 grams to 50 or less, with subsequent return of the labs to normal ranges.
I only had a few quibbles with the book. For instance, there’s no index, but that’s mitigated by a very detailed table of contents. The font size is on the small side for my 60-year-old eyes. If either of those issues bother you, get the ebook version. “Net carbs” are mentioned briefly before they are defined, which might confuse folks new to low-carbing.
A particular feature that appealed to me is the vegetarian meal options. Low-carb eating is often criticized as being meat-centric. Franziska shows it doesn’t have to be.
I also appreciate that she provides the net carb grams and calorie counts for her meal plans and recipes. All diabetics and many prediabetics need to know the carb grams. Calorie counts come in handy when analyzing the cause of a weight loss stall. Yes, calories still count in weight management.
I don’t think it’s giving too much away to say that the author’s top low-carb beauty foods are avocados, berries, cinnamon, cocoa/dark chocolate, fatty fish, flaxseed, full-fat dairy, green tea, nuts, olives/olive oil, and non-starchy vegetables. I was skeptical at the start of the beauty foods chapter, but Franziska’s scientific references support her recommendations. I’m already eating most of these foods. Now I’m going to try green tea and ground flaxseed (e.g., her flaxseed bread recipe).
The author will also get you going on exercise. I heartily agree with her that exercise is truly a fountain of youth.
Menopausal? The author has your special challenges covered.
If you’re curious about the paleo diet, note that only about a quarter of these recipes are pure paleo. Dairy products disqualify many of them.
Here are a just a few tidbits I picked up, to help me remember them:
- a blood test called fructosamine reflects blood sugar levels over the previous three weeks
- you’ll have less wrinkles if you can reduce the advanced glycation end-products (AGEs) in your skin
- Japanese women on the highest-fat diets have less wrinkling and better skin elasticity
- soluble fiber from plants helps to reduce appetite, improves blood sugar control, and helps with weight regulation (see her table of high-fiber plants, including soluble and insoluble fiber)
- seitan is a meat substitute for vegetarians
- erythritol (an artificial sweetener) may have less gastrointestinal effects (diarrhea, gas, bloating) than many other artificial sweeteners
- maltitol (another artificial sweetener in the sugar alcohols class) tends to increase blood sugar more than the other sugar alcohols
- I’m going to try her “sardines mashed with avocados” recipe (Alton Brown popularized sardine-avocado sandwiches, so it’s not as bizarre as it sounds!)
I wouldn’t be surprised if Franziska’s recommendations help men as well as women keep or regain their youthfulness.
Georgia Ede, M.D., has a good article on constipation that is sometimes seen with ketogenic diets. Some think it’s related to low fiber content of the diet. But Dr. Ede found a study that indicates cutting down on fiber consumption helps alleviate constipation! A quote from the good doctor:
If you experience constipation on a ketogenic diet, it is not because you are eating less fiber; it is most likely because you have started eating something that you were not eating before (or a larger amount of something you didn’t eat much of before) that is hard for you to digest. In order to eat a ketogenic diet, which is a high-fat, limited protein, ultra-low-carb diet, most people find themselves turning to high amounts of foods that are notoriously difficult to digest, including nuts, low-starch vegetables such as crucifers, and full-fat dairy products.These foods just so happen to be 3 of the top 5 causes of chronic constipation, regardless of what kind of diet you choose to eat.
Read the whole enchilada for her tips on countering constipation. Another trick that works for many folks is cabbage soup.
A well-designed ketogenic diet is a great weight to reduce elevated blood sugars. Don’t let constipation dissuade you.
Compared to a mildly carbohydrate-restricted American Diabetes Association diet, a very-low-carbohydrate ketogenic diet was more effective at controlling type 2 diabetes and prediabetes, according to University of California San Francisco researchers.
Thirty-four overweight and obese type 2 diabetics (30) and pre diabetics (4) were randomly assigned to one of the two diets:
- MCCR: American Diabetes Association-compliant medium-carbohydrate, low-fat, calorie-resticted carb-counting diet. The goals were about 165 grams of net carbs daily, counting carbohydrates, an effort to lose weight by eating 500 calories/day less than needed for maintenance, and 45–50% of total calories from carbohydrate. Protein gram intake was to remain same as baseline. (Note that most Americans eat 250–300 grams of carb daily.)
- LCK: A very-low-carbohydrate, high-fat, non-calorie-restricted diet aiming for nutritional ketosis. It was Atkins-style, under 50 grams of net carbs daily (suggested range of 20–50 g). Carbs were mostly from non-starchy low-glycemic-index vegetables. Protein gram intake was to remain same as baseline.
Baseline participant characteristics:
- average weight 100 kg (220 lb)
- 25 of 34 were women
- average age 60
- none were on insulin; a quarter were on no diabetes drugs at all
- most were obese and had high blood pressure
- average hemoglobin A1c was about 6.8%
- seven out of 10 were white
Participants followed their diets for three months and attended 13 two-hour weekly classes. Very few dropped out of the study.
Average hemoglobin dropped 0.6% in the LCK group compared to no change in the MCCR cohort.
A hemoglobin A1c drop of 0.5% or greater is considered clinically significant. Nine in the LCK group achieved this, compared to four in the MCCR.
The LCK group lost an average of 5.5 kg (12 lb) compared to 2.6 kg (6 lb) in the MCCR. The difference was not statistically significant, but close (p = 0.09)
44% in the LCK group were able to stop one or more diabetes drugs, compared to only 11 % in the other group
31% in the LCK cohort were able to drop their sulfonylurea, compared to only 5% in the MCCR group.
By food recall surveys, both groups reported lower total daily caloric intake compared to baseline. The low-carbers ended up with 58% of total calories being from fat, a number achieved by reducing carbohydrates and total calories and keeping protein the same. They didn’t seem to increase their total fat gram intake;
The low-carbers apparently reduced daily carbs to an average of 58 grams (the goal was 20-50 grams).
There were no differences between both groups in terms of C-reactive protein (CRP), lipids, insulin levels, or insulin resistance (HOMA2-IR). Both groups reduced their CRP, a measure of inflammation.
LCK dieters apparently didn’t suffer at all from the “induction flu” seen with many ketogenic diets. They reported less heartburn, less aches and pains, but more constipation.
Hypoglycemia was not a problem.
If I recall correctly, the MCCR group’s baseline carb grams were around 225 g.
Very-low-carb diets help control type 2 diabetes, help with weight loss, and reduce the need for diabetes drugs. An absolute drop of 0.6% in hemoglobin A1c doesn’t sound like much, translating to blood sugars lower by only 15–20 mg/dl (0.8–1 mmol/l). But remember the comparator diet in this study was already mildy to moderately carbohydrate-restricted. At least half of the type 2 diabetics I meet still tell my they don’t watch their carb intake, which usually means they’re eating around 250–300 grams a day. If they cut down to 58 grams, they most likely will see more than a 0.6% drop in hemoglobin A1c after switching to a very-low-carb diet.
This is a small study, so it may not be reproducible in larger clinical trials and other patient populations. Results are consistent with several other similar studies I’ve seen, however.
Reference: Saslow, Laura, et al (including Stephen Phinney). A Randomized Pilot Trial of a Moderate Carbohydrate Diet Compared to a Very Low Carbohydrate Diet in Overweight or Obese Individuals with Type 2 Diabetes Mellitus or Prediabetes. PLoS One. 2014; 9(4): e91027. Published online Apr 9, 2014. doi: 10.1371/journal.pone.0091027 PMCID: PMC3981696
PS: When I use “average” above, “mean” is often a more accurate word, but I don’t want to have to explain the differences at this time.
PPS: Carbsane Evelyn analyzed this study in greater detail that I did and came to different conclusions. Worth a read if you have an extra 15 minutes.