Category Archives: ketogenic diet

November 10, 2009 · 2:00 AM

Low-Carb Ketogenic Diet Beats Low-Glycemic Index Diet in Overweight Type 2 Diabetes

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Avoid the needle with a low-carb ketogenic diet

Duke University (U.S.) researchers demonstrated better improvement and reversal of type 2 diabetes with an Atkins-style diet, compared to a low-glycemic index reduced-calorie diet.

Methodology

Ninety-seven overweight and obese adults, 78% women and 40% black, were randomly assigned to either:

  • a very low-carb ketogenic diet (Atkins induction phase, as in Atkins Diabetes Revolution) or
  • a low glycemic-index index calorie-restricted diet (The GI Diet by Rick Gallop). 

Thirty-eight were in the Atkins group; 46 in the low-glycemic index (low-GI) group.  Seventeen dropped out of each group before the end of the 24-week study.  Average weight was 234.3 pounds (106.5 kg); average body mass index was 37.  The Atkins group averaged 13% of total calories from carbohydrate; the low-GI cohort averaged 44%. 

Results

Both groups lost weight and had improvements in hemoglobin A1c, fasting insulin, and fasting glucose. 

The Atkins group lowered their hemoglobin A1c by 1.5% (absolute drop, not relative) versus 0.5% in the other group. 

The Atkins group lost 11.1 kg versus 6.9 kg in the other group. 

The Atkins group increased HDL cholesterol by5.6 mg/dl versus no change in the other group. 

All the aforementioned comparisons were statistically significant. 

Diabetes medications were stopped or reduced in 95% of the Atkins group versus 62% of the low-GI group.

Total and LDL cholesterol levels were unchanged in both groups. 

Triglycerides fell significantly only in the Atkins group.

My Comments

You may be interested to know that this study was funded by the Robert C. Atkins Foundation.

One strength of this study is that it lasted for 24 months.  Many similar studies last only eight to 12 weeks.  A drawback is that, with all the drop-outs,  the number of participants is low. 

The GI Diet performed pretty well, too, all things considered.  Sixty-two percent reduction or elimination of diabetes drugs—not bad.  For a six-year-old book, it’s still selling fairly well at Amazon.com.  That may be why they chose it as the comparison diet.

The diet with fewer carbohydrates—Atkins induction—was most effective for  improving control of blood sugars.  So effective, in fact, that the researchers sound a note of warning:

For example, participants taking from 40 to 90 units of insulin before the study were able to eliminate their insulin use, while also improving glycemic control.  Because this effect occurs immediately upon implementing the dietary changes, individuals with type 2 diabetes who are unable to adjust their own medication or self-monitor their blood glucose should not make these dietary changes unless under close medical supervision.  

[Not all insulin users were able to stop it.]

Overall, lipids were improved or unchanged in the Atkins group, despite the lack of limits on saturated fat intake.  A common criticism of the Atkins diet is that it has too much saturated fat, leading to higher total and LDL cholesterol levels, which might raise long-term cardiovascular risks.  Not so, here. 

When you reduce carbohydrate intake, the percentages of fat and protein in the diet also change.  In this Atkins diet, protein provided 28% of daily calories, and fat 59%.  In the low-GI diet, protein provided 20% of daily calories, fat 36%.  The beneficial effects of the Atkins diet probably reflect the low carbohydrate consumption rather than high protein and fat. 

The Atkins induction-phase diet was clearly superior to the low-glycemic index diet in this overweight diabetic sample, without restricting calories.

Steve Parker, M.D.

Reference:  Westman, Eric, et al.  The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus.  Nutrition & Metabolism 2008, 5:36   doi:10.1186/1743-7075-5-36

Additional Reading

Samaha, F., et al.  A low-carbohydrate as compared with a low-fat diet in severe obesity.  New England Journal of Medicine, 348 (2003): 2,074-2,081.

Boden, G., et al.  Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes.  Annals of Internal Medicine, 142 (2005): 403-411.

Vernon, M., et al.  Clinical experience of a  carbohydrate-restricted diet: Effect on diabetes mellitus.  Metabolic Syndrome and Related Disorders, 1 (2003): 233-238.

Yancy, W., et al.  A pilot trial of a low-carbohydrate ketogenic diet in patients with type 2 diabetes.  Metabolic Syndrome and Related Disorders, 1 (2003): 239-244.

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October 22, 2009 · 3:38 PM

Centrum Multivitamin/Multimineral Supplement

1 or 2 Centrums daily

1 or 2 Centrums daily

I recommend Centrum for people on the Ketogenic Mediterranean Diet.  Since the composition of plain Centrum could change at any time (or be concocted differently in non-U.S. countries), I’m recording the contents of the current U.S. product.   Here are the component amounts with “% Daily Values” in parentheses. 

U.S. government authorities recommend Percent Daily Values for average non-pregnant healthy adults eating 2,000 calorie a day.

Vitamin A 3,5000 IU (70%), Vitamin C 60 mg (100%), Vitamin D 400 IU (100%), Vitamin E 30 IU (100%), Vitamin K 25 mcg (31%), Thiamin 1.5 mg (100%), Riboflavin 1.7 mg (100%), Niacin 20 mg (100%), Vitamin B5 2 mg (100%), Folic Acid 400 mcg (100%), Vitamin B12 6 mcg (100%), Biotin 30 mcg (10%), Pantothenic Acid 10 mg (100%), Calcium 200 mg (20%), Iron 18 mg (100%), Phosphorus 20 mg (2%), Iodine 150 mcg (100%), Magnesium 50 mg (13%), Zinc 11 mg (73%), Selenium 55 mcg (79%), Copper 0.5 mg (25%), Manganese 2.3 mg (115%), Chromium 35 mcg (29%), Molybdenum 45 mcg (60%), Chloride  72 mg (2%), Potassium 80 mg (2%), Boron 75 mcg, Nickel 5 mcg, Silicon 2 mg, Tin 10 mcg, Vanadium 10 mcg.

Why Centrum?

It’s been around for years and  has a good reputation.  It’s widely available at a reasonable price.  This is not a paid endorsement, in case you’re wondering.  Let me know if you think my faith is misplaced.  

–Steve

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October 21, 2009 · 10:09 AM

Recap of My Ketogenic Mediterranean Diet: Weeks 5-7

 

Drilling down into the data

Drilling down into the data

Body Stats

My weight is 155 lb now compared with160.5 at the end of Week 4.  I seem to have plateaued around 155 over the last few weeks.  Waist circumference is 34.25 inches, down an inch over the last three weeks.  This is a pretty good weight for me.

What am I eating? 

Ninety percent of my food consists of:

eggs (3/day), mozarella string cheese sticks, nuts (almonds, mixed, peanuts), steak, sausage, hamburger, chicken, canned tuna, canned sardines, tomatoes, onions, avocadoes, cucumbers, baby spinach, celery, romaine lettuce, red wine (7 fl oz/day), extra virgin olive oil, sugar snap peas, butter, Italian vinaigrette dressing, mayonnaise (on tuna), salt, pepper.  [You and I should eat greater variety of vegetables and nuts.]

Nutrient Analysis  (thanks to NutritionData.com)

Average daily calories: 1,800

Macronutrient percentages: 8% carbohydrate, 30% protein, 53% fat, 9% alcohol

Daily digestible carbohydrates: 25 g

Daily fats: 110 g total fat, 31 g saturated fat, 52 g monounsaturated fats

Daily cholesterol: 800 mg (mostly from eggs)

Daily fiber: 7-10 g

Daily sodium: 1,500 mg (not counting salt from shaker)

Any potential micronutrient deficiencies? 

Yes.  Considering the amounts of the various foods I’m eating, the un-supplemented Ketogenic Mediterranean Diet on many, if not most, days would be deficient in vitamins D, E, K, thiamin, folate, and pantothenic acid, and the minerals calcium, iron, magnesium, potassium, sodium, copper, manganese.  Less often, there are deficiencies of zinc and vitamins A, C, B12, riboflavin, and B6.  [I’m using table salt from the shaker but not tracking it; sodium deficiency is very unlikely.]

These potential deficiencies are based on the % Daily Values recommended by U.S. government authorities for an adult eating 2,000 calories daily.  Someone following the Ketogenic Mediterranean Diet but eating a different mixture of foods could have a better or worse micronutrient profile.

Version 1.01 of the Ketogenic Mediterranean Diet from the outset recommended one daily Centrum multivitamin/multimineral supplement, plus extra vitamin D 400 IU/day, and elemental calcium 500-1,000 mg/day.  These would prevent a large majority of these potential deficiencies. 

I started a daily magnesium supplement a week ago to suppress nocturnal leg cramps.  It’s working well.

Implications

I’m in the midst of revising my recommended supplements and will post them here within the next few days.  I’m likely to add magnesium, potassium, table salt, and fiber. 

Remember, this is not a life-long eating plan; it’s a temporary weight-loss program.  Natural sources of vitamins and minerals along with phytonutrients will be added later.

Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary, nutritional supplement, or exercise changes.

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September 7, 2009 · 2:08 AM

Do Grape Products Other Than Wine Affect Heart Disease Risk?

"Grapes may be just as healthful as wine"

"Grapes may be just as healthful as wine"

Grape products favorably affect four risk factors for heart disease, according to a scientific review published last year.

The “French Paradox” refers to the fact that certain regions of France have low levels of heart disease despite high consumption of saturated fats that supposedly cause heart disease.  Some have explained away the paradox by noting high consumption of red wine in those areas, which could counteract the adverse effects of saturated fats.  Others have used the paradox to indict the Diet-Heart Hypothesis itself. 

Wine, especially red wine, is an integral part of the Ketogenic Mediterranean Diet.  However, many people just don’t like wine, and others shouldn’t be drinking it.  So, I’ve been wondering if grape products other than wine might have the healthy effects of wine.

The reference article below reviewed grape product trials published over the previous 13 years: 34 studies in animals, 41 in humans.  In addition to wine, grape products included grape juice, grape seed, grape skin, grape pomace, and polyphenol-rich extracts.  The authors conclude that grape products have the following beneficial effects on cardiovascular risk factors:

  • lower blood pressure, mainly due to release of nitric oxide from cells lining the arteries
  • reduced levels of total cholesterol, LDL cholesterol (“bad cholesterol”), and trigylcerides, especially if these values are high at baseline
  • reduced development of early-stage atherosclerosis (less LDL oxidation and plaque formation)
  • improved antioxidant status

Here are some grape product “fun facts” from the article:

  • healthy effects are primarily attributed to polyphenols, which are strong antioxidants that disable free radicals and chelate metals
  • major grape polyphenols are anthocyanins in red grapes, flavon-3-ols in white grapes
  • red grapes have more total polyphenols than white grapes
  • the main polyphenols in wine are resveratrol, tannins, flavan-3-ols, flavan-3,4-diols, anthocyanins, flavonols, flavones, anthocyanins, and anthocyanidins
  • red wine has a much higher phenolic content than white wine

Unfortunately, the authors never make any specific recommendations for people wanting to substitute alcohol-free grape products for wine.  

But I bet if you went down to your local vitamin or health food store, you could find some grape extracts or other grape products to try.  Anyone on a very low-carb diet would want to be sure the grape product wouldn’t supply more than 3-4 grams of digestible carbohydrate per day.  For those not on such a diet, purple grape juice like Welch’s—4 to 8 fl oz a day—is a good alternative to wine.  Welch’s has 42 g of carbohydrate per 8 fl oz. 

Steve Parker, M.D.

Disclaimer:  All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Reference:  Perez-Jimenez, Jara and Saura-Calixto, Fulgencio.  Grape products and cardiovascular disease risk factors.  Nutrition Research Reviews, 21 (2008): 158-173.

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June 24, 2009 · 2:00 AM

High Protein Ketogenic Diet Beats High Protein/Medium Carb Diet in Men, at Least Short-Term

Low-Carb Steak

Low-Carb Steak

Scottish researchers last year reported greater weight loss and less hunger in obese men on a high-protein ketogenic diet compared to a high-protein, moderate-carbohydrate diet.

Background

Dietary protein seems to be more satiating – able to satisfy hunger, that is – than carbohydrate and fat. 

The typical Western (especially American) diet derives about 55-60% of total calories from carbohydrates.  When carbohydrate intake is very low, under 20-30 grams per day for example, fat stores are utilized as a source of energy to replace carb calories, resulting in fat breakdown waste products called ketone bodies.  These are ketogenic diets.  In them, carbs are replaced usually by both extra fat and extra protein. 

Methodology

Each of 17 obese men, 20 to 65 years old, were placed on two separate diets for four weeks each time.  Average weight was 111 kg.  Average body mass index was 35.  This was a residential program, but the subjects were allowed to leave and go to work.

  • Diet 1:  high-protein, low-carbohydrate, ketogenic.  30%, 4%, and 66% of energy (calories) as protein, carbohydrate, and fat, respectively.
  • Diet 2:  high-protein, medium-carbohydrate, nonketogenic.  30%, 35%, and 35% of calories as protein, carb, and fat, respectively.

Actually 20 men signed up, but three dropped out for personal reasons after starting. 

They could eat as much as they wanted. 

Results

Subjects had no overall preference for either diet.  No differences in the diets for desire to eat, preoccupation with food, or fullness.  Weight loss was greater for the low-carb diet tahn with the medium-carb diet: 6.34 kg vs 4.35 (P < 0.001).  Subjects lost more weight on their first diet than on their second.  Fasting glucose and HOMA-IR (a test of insulin resistance) was lower than baseline for the low-carb diet but not the other.  Total and LDL cholesterol were tended to fall in response to both diets, but to a statistically significantly great degree only on the medium-carb diet.  When eating the low-carb diet, subjects ate 300 calories per day less than on the medium-carb diet.  [ketones were measures?]

Discussion

We have to assume that study subjects were of Scottish descent.  Applicability of these results to other ethnic groups is not assured.  Similarly, results don’t necessarily apply to women.

I’m surprised the medium-carb dieters, eating all they wanted, lost weight at all.  Must be a result of the high protein content or lower-than usual carbohydrate content of the study diet.  Study authors cite others who found that doubling protein intake from 15 to 30% of calories reduces food intake, which should lead to weight loss. 

Since protein content was the same on both diets, the greater weight loss seen on the low-carb ketogenic diet was the result of lower caloric intake, in turn due to less hunger.  The reduced energy intake could be due to lower carb or higher fat intake, or both.  The researchers cite one study finding no satiating effect of fat.  Some say that ketone bodies reduce appetite. 

Although the medium-carb diet showed greater improvements in total and LDL cholesterol, the low-carb diet changes trended in the “right” direction (down).

On the low-carb ketogenic diet, lower glucose levels and insulin resistance would tend to help people with (or prone to) type 2 diabetes, prediabetes, and some cases of metabolic syndrome. 

Steve Parker, M.D.

 References: 

Johnstone, Alexandra, et al.  Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum.  American Journal of Clinical Nutrition, 87 (2008): 44-55.

Weigle, D.S., et al.  A high-protein diet induces sustained reductions in appetite, ad libitum caloric intake, and body weight despite compensatory changes in diurnal plasma leptin and ghrelin concentrations.  American Journal of Clinical Nutrition, 82 (2005): 41-48.

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May 25, 2009 · 9:31 AM

Spanish Ketogenic Mediterranean Diet

Altea, Plaça de la EsglésiaEver heard of the Spanish Ketogenic Mediterranean Diet?  It looks like a low-carb quasi-Mediterranean diet.

Researchers with the University of Cordoba in Spain studied 40 subjects eating a low-carb “Mediterranean” diet for 12 weeks.  The results were strikingly positive.

Methodology

A medical weight loss clinic was the source of 40 overweight subjects, 22 males and 19 females, average age 38, average body mass index 36.5, average weight 108.6 kg (239 lb).  These folks were interested in losing weight, and were not paid to participate.

Nine subjects were not included in the final analysis due to poor compliance with the study protocol (3), the diet was too expensive (1), a traumatic car wreck (1), or were simply lost to follow-up (4).  So all the data are pooled from the 31 subjects who completed the study.

Blood from all subjects was drawn just before the study began and again after 12 weeks of the diet.

Study diet:  Low-carbohydrate, high in protein [and probably fat, too], unlimited in calories.  Olive oil was the main source of fat (at least 30 ml daily).  Maximum of 30 grams of carbohydrates daily as green vegetables and salad.  200-400 ml daily of red wine.  The authors write:

Participants were permitted 3 portions (200 g/portion) of vegetables daily: 2 portions of salad vegetables (such as alfalfa sprouts, lettuce, escarole, endive, mushrooms, radicchio, radishes, parsley, peppers, chicory, spinach, cucumber, chard and celery), and 1 portion of low-carbohydrate vegetables (such as broccoli, cauliflower, cabbage, artichoke, eggplant, squash, tomato and onion).  3 portions of salad vegetables were allowed only if the portion of low-carbohydrate vegetables were not consumed.  Salad dressing allowed were: garlic, olive oil, vinegar, lemon juice, salt, herbs and spices.

The minimum 30 ml of olive oil were distributed unless in 10 ml per principal meal (breakfast, lunch and dinner).  Red wine (200–400 ml a day) was distributed in 100–200 ml per lunch and dinner.  The protein block was divided in “fish block” and “no fish block”.  The “fish block” included all the types of fish except larger, longer-living predators (swordfish and shark).  The “no fish block” included meat, fowl, eggs, shellfish and cheese.  Both protein blocks were not mixed in the same day and were consumed individually during its day on the condition that at least 4 days of the week were for the “fish block”.

Trans fats (margarines and their derivatives) and processed meats with added sugar were not allowed.

Vitamin and mineral supplements were given.

Subjects measured their ketosis state every morning with urine ketone strips.

Results (averaged)

  • Body weight fell from 108.6 kg (239 lb) to 94.5 kg (209 lb), or 2.5 pounds per week
  • Body mass index fell from 36.5 to 31.8
  • Systolic blood pressure fell from126 to 109 mmHg
  • Diastolic blood pressure fell from 85 to 75 mmHg
  • Total cholesterol fell from 208 to 187 mg/dl
  • LDL chol fell from 115 to 106 mg/dl
  • HDL chol rose from 50 to 55 mg/dl
  • Fasting glucose dropped from 110 to 93 mg/dl
  • Triglycerides fell from 219 to 114 mg/dl
  • No significant differences in male and female subjects
  • No adverse reactions are mentioned

Researchers’ Conclusions

The SKMD [Spanish Ketogenic Mediterranean Diet] is safe, an effective way of losing weight, promoting non-atherogenic lipid profiles, lowering blood pressure and improving fasting blood glucose levels.  Future research should include a larger sample size, a longer term use and a comparison with other ketogenic diets.

My Comments

The researchers called this diet “Mediterranean” based on olive oil, red wine, fish, and vegetables.

What’s “Not Mediterranean” is the paucity of carbohydrates (including whole grains); lack of yogurt, nuts, and legumes; and the high meat/protein intake.

The emphasis on olive oil, red wine, and fish could make this healthier than other ketogenic diets.

Ketogenic diets are notorious for high drop-out rates compared to other diets.  Most people can follow a ketogenic diet for only two or three months.  But several studies suggest greater short-term weight loss for people who stick with it.  Efficacy and superiority are little different from other diets as measured at one year out.

Many of the metabolic improvements seen here might be duplicated with loss of 30 pounds (13.6 kg) over 12 weeks using any reasonable diet.

Average fasting blood sugars in these subjects was 109 mg/dl.  Although not mentioned by the authors, this is in the prediabetes range.  The diet reduced average fasting blood sugar to 93, which would mean resolution of prediabetes.  Dropping body mass index from 36 to 32 by any method would tend to cure prediabetes.

Elevated blood sugar is one component of the “metabolic syndrome.”  Metabolic syndrome was recently shown to be reversible with a Mediterranean diet supplemented with nuts.

I suspect this would be a good program for an overweight person with uncontrolled type 2 diabetes, too.  But it has never been studied in a diabetic population.  So, who knows for sure?

If you’re thinking about doing something like this, get more information and be sure to get your doctor’s approval first.

Steve Parker, M.D.

Addendum:

On April 6, 2008, I had a delightful conversation with Jimmy Moore, of Livin’ La Vida Low-Carb fame regarding this study.  It struck me that the Spanish Ketogenic Mediterranean Diet is probably higher in protein and lower in fat than many other ketogenic weight-loss diets.  Since fish is emphasized over other animal-derived foods, it’s likely also lower in saturated fat.  [In low-carb diets, carbohydrates are substituted with either fats or proteins.]  I’m also convinced I will eventually have to review the validity of the dogmatic diet-heart hypothesis:  Dietary saturated fat, total fat, and cholesterol contribute to atherosclerosis and associated premature death from heart attacks and strokes.

References and Additional Reading:

Perez-Guisado, J., Munoz-Serrano, A., and Alonso-Moraga, A.  Spanish Ketogenic Mediterranean diet: a healthy cardiovascular diet for weight loss.  Nutrition Journal, 2008, 7:30.   doi:10.1186/1475-2891-7-30

Bravata, D.M., et al.  Efficacy and safety of low-carbohydrate diets: a systematic review.  Journal of the American Medical Association, 289 (2003): 1,837-1,850.

Gardner, C.D., et al.  Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial.  Journal of the American Medical Association, 297 (2007): 696-677.

Stern, L., et al.  The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial.  Annals of Internal Medicine, 140 (2004): 778-785.

Shai, Iris, et al.  Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet.  New England Journal of Medicine, 359 (2008): 229-241.

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