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My Thoughts on Low-Carbohydrate Ketogenic Diets, Part 2

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When I first started this website a little over a year ago, I did so with the intention of discussing low-carb diet research and other low-carb topics. So I want to thank any long-time (well, at least a year!) followers who have stayed with me despite my veering off course now and then.  In the beginning I was very green with respect to the benefits carbohydrate restriction as a viable option for blood sugar and weight management (in my training as a dietitian, the Atkins diet was routinely dismissed as unhealthy and unsustainable), and I began spending a lot of time on dozens of low-carb sites, including many with a Paleo/Primal approach. The Paleo diet seemed quite healthy:  It was based on whole foods, grass-fed meat, and organic plant foods. However, it contained a lot less dairy and nuts than I was eating and which I continued to consume in fairly large amounts.

In the latter part of 2011, I began adding in some starchy foods like sweet potatoes and rice based on recommendations found on various Paleo sites. Although I’d been consuming 30-35 grams of total carbs per meal at that point with occasional postprandial hyperglycemia, the addition of starchy foods definitely worsened my blood glucose control, particularly after lunch and dinner (for some reason my post-breakfast readings were and are almost always good).  Researching other people’s online experiences with reintroducing starch reassured me that this was likely a temporary thing that would improve as my body adapted to eating this type of food again. I continued eating the same way and monitoring my blood sugar about three or four times a week.

I tried not to get too upset seeing my readings routinely in the 150s-170s and occasionally as high as 200 an hour after eating, telling myself it would eventually get better. But after 9 months, it never did. Even replacing the starches with an equivalent amount of carbohydrate from fruit or dairy didn’t help. Although others may be able to tolerate higher amounts of carbohydrate after a reasonable adjustment period, I had to admit that this wasn’t the case for me.  I was already eating pretty low carb (about 90-110 grams total or 65-80 grams net daily), so where to go from there? Obviously, lowering my carb intake was the only thing I could do, short of medication. And since my fasting blood sugar has remained normal, there weren’t a lot of pharmalogical options anyway.

In researching my ADA article on low carbohydrate diets, I found a study in which many subjects on a very-low-carbohydrate, ketogenic diet (VLCKD) achieved such significant improvements in blood sugar that they were able to greatly reduce or even discontinue their diabetes medication. There is also research on the hormonal benefits of VLCKDs for polycystic ovarian syndrome (PCOS) as well as weight loss. In addition, I found  many online anecdotal reports  of improved mental clarity and well being with this approach.  So I decided to reduce my carb intake further and begin eating  a VLCKD containing 40-50 grams of net carbs per day. To be honest, although I’ve been eating low-carb for about a year and a half, I had some sort of mental block about not wanting to go into ketosis. I’d done enough research to know it wasn’t dangerous, but I still resisted the idea on some level. A few months ago I wrote a post stating I didn’t think it was necessary for most people. Turns out it may have been just what I needed.

Although it’s only been 6 days, the results so far are pretty impressive.  My highest 1-hour postprandial reading has been 128, but most of the time I’m well below 120, and after 2 hours below 100.  I haven’t seen numbers like this in such a long time, and I must say it’s a welcome change!  In addition, I feel great, with more energy and focus but less
hunger — not a  surprise given my previous unstable postprandial blood sugar, coupled with the appetite suppression of ketosis.  I’ve lost a couple of pounds, which I know is water. I routinely count calories when I eat (again, that dietitian training!), and I’m consuming the same 1500-1800 I’ve been doing for years, so I don’t anticipate losing any additional weight, nor do I want to.  I know I’ll be perfectly happy eating a very small amount of fruit and avoiding starches entirely (maybe a small bite of dessert once in a while). Not to sound obnoxious, but anyone who knows me personally would say I’m a pretty disciplined eater (sometimes annoyingly so). In addition, I like all kinds of food and look forward to experimenting with very-low-carbohydrate recipes.

It’s quite apparent to me that eating at a ketogenic level is not only safe but could be very desirable for people with blood sugar or weight management issues. In my previous post, I said, “Starting off at ketogenic levels may provide a psychological benefit due to early rapid weight loss that usually occurs, but there is certainly no indication to remain in perpetual ketosis for weight management purposes.” But maybe for some people eating at this level indefinitely is appropriate. The T4 to T3 conversion problem I mentioned in that post most likely is due to cutting calories and losing weight rather than lower carb intake per se, as it occurs with all types of diets. I know that several doctors who follow the same VLCKDs they prescribe for their patients — including but not limited to Dr. Steve Phinney, Dr. Jeff Volek, Dr. Jay Wortman, and Dr. Richard K. Bernstein — enjoy this way of eating, remain very healthy, and plan to continue for the foreseeable future. Of course, I still feel people should decide how many carbs they feel comfortable eating based on their blood sugar levels, weight, and most importantly how they feel. I don’t think a ketogenic diet (or a nonketogenic low-carb diet, for that matter)  is for everyone, and I may ultimately decide it’s not the best fit for me. But I’m excited to learn more about the benefits of eating very low carb and will likely be blogging about these sometime soon.

***  I will end with my standard advice to always consult with your physician prior to adopting a low-carbohydrate diet or making any other dietary changes. You may also find the following books very helpful:
The Art and Science of Low Carbohydrate Living by Dr. Stephen D. Phinney and Dr. Jeff  S. Voleck
Dr. Bernstein’s Diabetes Solution: The Complete Guide to Achieving Normal Blood Sugars by Richard K. Bernstein, M.D.

References:
1. Yancy WS, et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab 2:34, 2005 
2. Mavropoulos JC, et al. The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study. Nutr Metab 2:35, 2005 
3. Manninen AH. Metabolic Effects of the Very-Low-Carbohydrate Diets: Misunderstood “Villains” of Human Metabolism. J Int Soc Sports 1(2)7-11, 2004. 


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29 Comments

  1. Jonathan Swaringen says:

    http://livinlavidalowcarb.com/blog/jimmy-moores-n1-experiments-nutritional-ketosis-day-1-30/14409

    Have you checked out Jimmy Moore’s nutritional ketosis experiment yet?

    Very exciting.

    Also this goes very well with that.

    http://drrosedale.com/blog/2012/08/18/a-conclusion-to-the-safe-starch-debate-by-answering-four-questions/

    http://jackkruse.com/brain-gut-6-epi-paleo-rx/

    Have you checked out Jack Kruse yet? I really like his stuff though his writing…leaves something to be desired at times. I’ve heard some good podcast interviews of him.

    1. Franziska says:

      No, haven’t had a chance to check out Jimmy’s and Ron’s posts but will be sure to do so! Yes, I’m familiar with Jack Kruse. Agree that he’s a great speaker but realize he’s rather controversial in some of his beliefs and approaches to treatment.

  2. “The T4 to T3 conversion problem I mentioned in that post most likely is due to cutting calories losing weight rather than lower carb intake per se, as it occurs with all types of diets.”

    Do you have a reference for this statement? This is very aligned with my thinking, but there are many claims in the Paleo community that low carbing causes hypothyroidism. Personally I saw improvement in my TSH by adding calories but keeping my carb levels low.

    1. Franziska says:

      Hi Janknitz,

      Unfortunately, I don’t have a reference. However, there has been so few well-designed studies done on carb restriction’s effect on thyroid health, and most of the research that does exist is decades old. One more recent study did not measure free T3 but found but no change in T3 uptake; in addition, improvement in body composition occurred: http://www.ncbi.nlm.nih.gov/pubmed/12077732

      I’m glad your TSH level improved with additional calories. The more I think about it, it seems that adequate energy/calories is most important for thyroid health.

      1. And I’m glad to see you coming around on this topic. It seems like too many people are making the assumption that low carb is causing hypothyroidism and there doesn’t seem to be any scientific evidence to back up that claim.

        Meanwhile, people “on the insulin resistance spectrum” can benefit from cutting carbs down to ketogenic levels, but many are dissauded from doing so by people who think they “know” that ketogenic diets adversely affect thyroid function.

  3. Stephen Ferguson says:

    I was diagnosed with T2D in April 2010, with a HbA1c of 10.2% (and a BG reading of 470mg/dl.

    By eating <25g of carb a day, I've managed to shed 60lbs, cut my HbA1c to 4.9% (a properly non-diabetic level) and gone from being a couch potato to running half-marathons.

    Ketsosis has made me happier, healthier and fitter than any time in my life.

    1. Franziska says:

      Wow, those are some phenomenal accomplishments! I’m so happy to hear this. You are an example of what is possible for many people with diabetes. Way to go! 🙂

  4. Aglaee, Paleo RD says:

    I am glad it works for you. I also have to stay below 30-40 g of total carbs a day to keep my weight, PCOS and blood sugars under control. I have been eating this way for almost 2 years now without any unwanted side effects! I don’t think everybody has to do that, but people like us definitely should give it a try to see if it works for them. 🙂

  5. Franziska says:

    Thanks so much for your comments, Aglaee! It’s great to know there’s at least one other RD who’s doing well on a very-low-carbohydrate diet 🙂 I’m hoping that someday these recommendations won’t be seen as heretical within the nutrition community.

  6. Dan Brown says:

    Someone on Dr. Bernstein’s Diabetes Forum linked to your blog, and I have enjoyed reading about you. Your training originally as a CDE, your epiphany after you saw your lab reports and used your common sense to eat to the meter, and then your gradual and very open minded transition through the two posts on the VLCKD, are an example of courage that many other health care professional would do well to follow. Don’t worry about who you please, and how many readers you will alienate. Just follow your meter. I predict you will find there are more and more of us who are just like you (metabolically speaking). We are insulin resistant and cannot tolerate carbohydrates. If you re-read Phinney and Volek’s introduction to “Low Carbohydrate Living,” you will see they phrase “carbohydrate intolerance” multiple times to impress that “new phras”e in our brains. It distinguishes us (the T2s and the prediabetics and the Metabolic Syndrome population from the Paleo/Aancestral crowd. Too bad but it’s too late for us. We just have to live with it, so to speak. Keep up the good work. You are now one of my “favorites.”

    1. Franziska says:

      Hi Dan,

      Thank you so much for your very kind words and feedback! I’ve always admired Dr. Bernstein’s work and know several people (including a very good friend) who follow his program with great results. I’m not quite a T1 or prediabetic/T2, as I am thin with no other signs of the metabolic syndrome and normal fasting BG do have those very high postprandial readings. At any rate, as you said, we simply can’t tolerate carbohydrates the way many others can, so instead we eat differently and learn to appreciate how we can control our numbers. Very happy to have you as a reader. I’ll be sure to check out your blog as well 🙂

  7. Franziska says:

    Janknitz,

    Unfortunately I’m unable to reply directly below your response. I can’t say for certain that lowering thyroid intake won’t impact thyroid function. I have hypothyroidism (low free T3 and T4 although TSH is also low on treatment) which did not improve when I increased carb intake. I’ll see what impact going VLC has on my thyroid when I have labs rechecked in December.

  8. Galina L. says:

    I have been eating my LC diet since nov.2007. It helps me to manage migraines and it eliminated pre-menopause symptoms. I also have other benefits like improving allergies and stopping all seasonal flues and infections. I am 51.

    1. Hi Galina,

      Thanks so much for your comments. I’m so glad eating a very-low-carb diet has been successful for you. I’m almost 46 and in perimenopause myself, so I can definitely relate. I recognize your name from a few other blogs I read (I’m more of a lurker ;)), and I’ve always enjoyed your astute perspectives on things.

  9. Galina L. says:

    Thank you, Franziska . I feel like we just had a hand shake. It is great that a person in your profession got interested in LCarbing as an acceptable diet. When my family doctor expressed his surprise that I didn’t request my asthma medication any longer and managed not to regain the lost weight, I told him about my diet regiment. He was not surprised at all, because , according to him, several of his patients had similar results, but he couldn’t recommend it as a treatment in appropriate cases because of LC not being the acceptable standard of care. Probably, many health-care professionals like you will start recommending people to just eat according to the bs meter while avoiding any labels, it could be more customized approach than just use a glycemic index. It could also put a stop on an endless discussion about the appropriate amount of carbs in a healthy diet because it is not universal.
    I also hope in a future more non-diabetic people will be using a blood sugar meter like they use a bp monitor, because it could give a lot of hints to a general population. Many times I heard people complaining on some horrible health-scares episodes which looked like just a hypoglycemic event. My mom found out with my help that her blood sugar meter normally displayed 167 number after a supposedly healthy breakfast of still-cut oats with dried apricots and prunes (in order to avoid a sugar and to get more potassium and fiber). Eating according to the meter normalized her blood pressure without medications to her big surprise.
    Thank you for having open minds

    1. Franziska says:

      Thank you, Galina. It’s true that carbohydrate restriction is not currently considered the standard of care, which is very unfortunate. In my day job as an outpatient dietitian at a large hospital, I do recommend lower carb intake but cannot at this point recommend VLC like Atkins or Bernstein. Hopefully this will change as health professionals become more open-minded and realize that a one-size-fits-all approach simply doesn’t work and that the majority of people with diabetes respond very well to carb restriction. To be honest, I took a pretty big risk by posting this blog entry but I felt compelled to speak my mind. You’re absolutely right about the blood sugar meter providing useful information to people without diabetes as well as those who have the disease. Great that your mom benefitted from your example!

  10. George Henderson says:

    You may even find that a sustained period of ketosis improves carb tolerance later on.
    My own policy is to eat a ketogenic diet for myself, but eat enough “safe starches”, once a day, to supply prebiotics for the microbiota.
    .

  11. Franziska says:

    Thanks for the info, George. It would be great to achieve a better response to carbs in the future. I can see where you’re coming from and appreciate you sharing your strategy for gut health. My goals are to remain as healthy and vibrant as possible for many years to come!

  12. BadmoonT2 says:

    Thanks for sharing your latest diet experiences Franziska. I admire your pragmatism and ability to change course when something is not working. It’s interesting that you have less trouble in the morning, for many of us this is the time dawn phenomenon causes our worst readings of the day.

    A recent study says there are 53 different genes that have an effect on glucose metabolism, and I suspect that number will grow in the future. No wonder different people have different responses to diet, one size definitely does not fit all. This is why the concept of “eating to your meter” is such a powerful one.

    Also thanks for the positive review of Diet 101: The Truth About Low Carb Diets,” I purchased it based on your review and am about half way through. I really enjoy Jenny’s ability to read studies and sort out the good from the poorly designed, as well as her ability to draw conclusions supported by the evidence and to frankly say “we don’t know the answer to that question”.

    1. Franziska says:

      Thanks so much for the nice feedback, BadMoonT2! I agree it’s strange that my postprandial a.m. sugars are best. Can’t figure out why, and I’ve not heard of others who find their highest readings after lunch.

      It’s so interesting how individulaized blood sugar response is. I look forward to learning more about the genetic influences as further research is done.

      Glad you’re enjoying Jenny’s new book. She’s amazing and so modest! Wonderful all around.

  13. gibson girl says:

    What a refreshing article, Franziska! I’m diabetic, pcos, hypothyroid and post-meno and doing well on a vlc paleo diet. I just choose whole foods and keep the carbs ~30g (I don’t count fiber). I stopped Actos within six months of starting the diet. I don’t feel deprived or hungry. I declined statins offered by my doctor. My lab work is normal and my fasting blood sugars are in the 80’s or low 90’s most of the time. A1c 5.3, down from 13 at dx.

    My dread is facing hospital or nursing home food and not having a choice. I appreciate you taking the risk of educating the medical community on this subject. Thank you!

    1. Franziska says:

      Thanks so much for your comments, gibson girl! Wonderful that you were able to discontinue diabetes meds and bring your blood sugar down to normal range by limiting carbs. Congratulations — an A1c of 5.3 is a huge accomplishment! I’m not a fan of statins either. If you’re hospitalized or placed in a long-term care facility (hopefully not anytime soon), you may or may not have a say in what is served, but you can do pretty well by eating the protein portion, ask for an extra serving of vegetables, and skipping all or most of the starch that typically accompanies a “consistent carbohydrate” meal. Best of luck, and again, great job! 🙂

  14. I just ran across this blog by searching low carb dietician. I read this post and was impressed by your ability to modify your diet (and your mind) in response to the meter. I have struggled with my weight for my entire life, along with the rest of my family. When I was in the sixth grade, my family was put on a high carb exchange diet by a dietician—which spun my weight completely out of control. I now control my weight by using the Atkins Nutritional Approach. I do all the work for putting together my menus by myself but was wondering if any dieticians had come around and pleasantly surprised to see your post. Best Wishes!

    1. Franziska says:

      Thanks so much for the nice feedback, Tamica! I’m so glad you’ve had success on Atkins, a plan often criticized by those who don’t really understand the science behind the diet. Fortunately, there are a number of doctors and a few dietitians who are also open to carbohydrate restriction. I wish you continued success with your low-carb lifestyle 🙂

  15. Hey Fransika,

    I am type 1 and have read and followed you within the low carb diabetes world and love how great you are about talking about these things. Do you have an update on your thyroid issues? I am also low freet3, freet4 and TSH and I have been treating it with NDT and following stop the thyrid maddness, but i still find so many posts that say low carb casues thyroid issues that I wonder if lower stable BG are worth an uncontrolled thyroid numbers 🙁 urgg lol

    1. Franziska Spritzler says:

      Hi Laura,

      Thanks so much for your comments and for sharing your concerns about carb restriction on thyroid health. I’m assuming you have Hashimoto’s as a type 1, so you’ll need thyroid replacement regardless of what you eat. I think optimal carb intake varies from person to person, and we need more research to see how different people do on <20 grams vs. 50 grams vs. 100 grams. Experiment to see how you feel best and what allows you to maintain good BG numbers as well.

      I don't have Hashimoto's, but I still have hypothyroidism and low T3 and T4 unless I take Armour thyroid daily. My thyroid levels have been stable for years on medication, and I feel fantastic with tons of energy -- pretty good considering I turn 50 later this year. But I'm no longer keto, although I always eat fewer than 50 grams net carb (60-80 grams total) daily.

      Best of luck to you, Laura!

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