Now that I've finally finished my article for the American Diabetes Association, I'd like to start by expressing my sincere appreciation for those who write scholarly articles and books. The time and effort it takes to produce accurate, substantive work is much more than many would expect. So to all the authors of my favorite nutrition books of 2011, thank you so much for the time you put in! My article was only a few pages long and took more hours than I care to admit. Fortunately, doing the research for it provided me with some good ideas for future blogs posts.
I was asked to write the article on a low-carbohydrate diet pattern for blood sugar and weight management in people with diabetes. The amount and type of carbohydrates to prescribe was at my own discretion, and I gave it very careful consideration after reviewing all of the available evidence. Although I've never personally cut carbs to the point necessary to induce ketosis, I was open to the possibility that there was evidence to warrant its use in diabetes and weight management. There has been a lot of research in this area within the past ten years, both short- and long-term studies, and I ended up citing 27 of them in the article. Traditional ketogenic diets are extremely low in carbohydrates (usually 10-15 grams per day) and have been used since the 1920s for the treatment of childhood epilepsy with very impressive results. There is also emerging evidence regarding their use in therapy for certain types of cancer and neurological disorders such as ALS and Parkinson's disease. Ketosis occurs when the body shifts from using glucose to ketone bodies and fatty acids as its primary fuel. The level at which this occurs varies somewhat among different people, but it's generally less than 50 grams per day. The most famous low-carbohydrate ketogenic diet (LCKD) is the Atkins Diet created by cardiologist Dr. Robert Atkins in the early 1970s. It is mainly used for weight loss but occasionally for blood sugar control as well. The plan involves starting off at an "induction phase" of 20 grams of carbohydrates and adding back carbs until reaching a "maintenance" level which is also individualized. Dr. Richard Bernstein, who has lived with Type 1 diabetes for more than 60 years, recommends strictly limiting carbohydates with the goal of achieving normal blood sugar levels. By keeping carbs within 30-35 grams per day and 6-12 grams meal, smaller insulin dosages are needed, resulting in less error in matching carbohydrate intake to insulin and more predictable blood sugars. For people with Type 2 diabetes not taking insulin, very-low-carbohydrate intake prevents post-meal blood glucose spikes. Is there any advantage to a VLCKD vs. a diet that is low in carbs but not low enough to promote ketosis? From the research I've seen, the answer is no with respect to the ketogenic aspect of the diet. The carbohydrate restriction itself is another matter, however. Do Dr. Bernstein and many other people with Type 1 and Type 2 diabetes experience better blood sugar control with carb intake at ketogenic levels? Definitely a very large portion do, but this is due to the diet's effect on blood sugar regulation. For these individuals, the benefits of VLCKDs may very well warrant its use. But for weight management, I just don't think that's the case. Millions of people have lost weight on Atkins or other low-carbohydrate plans, but many have never achieved their personal weight goals, and most have regained at least a portion of the weight back. Although it doesn't work for everyone, I do believe a low-carbohydate diet can help people lose and maintain weight. 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. While many low-carb proponents speak of a "metabolic advantage" that occurs with ketosis, characterized as turning your body into a fat-burning machine, I have found no convincing research to support this. It appears that the mechanism responsible for weight loss is a spontaneous reduction in calories due to reduced hunger and greater satiety on both low-carb diets and VLCKDs. And once a person reaches a certain weight, if the caloric intake is too high to promote further loss at this new weight, then weight loss will stall regardless of whether carb intake remains at ketogenic levels or not. There may be another reason for slowed weight loss on a VLCKD. Recently, there have been several posts on various paleo/ancestral blogs regarding problems people have encountered on low-carb diets. I hadn't really been following this issue that closely since I was doing a lot of lit review for the article. But it seems the main issues people have encountered are failing to sustain continued weight loss despite keeping carbs low, an inability to stay warm, and fatigue. These are symptoms of potential thyroid dysfunction (among other things). There is a good amount of research indicating that people may develop problems converting the thyroid hormone thyroxine (T4) to the active hormone triiodothyronine (T3) and instead convert a greater than normal portion to the inactive form, reverse T3 (RT3) at lower carbohydrate intakes, with the effect being more pronounced at ketogenic levels. In certain individuals this may result in lower resting metabolic rate. It's important to note that this does not happen to everyone on VLCKDs, however, and thyroid function is very complex and affected by many factors in addition to carbohydrate and caloric intake. I'm sure I'll probably lose several followers after this post, but I have to be honest and state my true beliefs as a dietitian and fellow low-carber. I've never advocated a ketogenic approach for weight management, and I received some very unpleasant e-mails and comments on another member's Facebook page when I recommended staying above 20 grams of carbs per day. (In that post, I neglected to mention the exceptions of treating epilepsy and possibly cancer and neurological disorders). As an outpatient dietitian in a large hospital, I counsel many people who are not even remotely interested in following a low carbohydrate diet, and that's fine. People can certainly lose weight and even control blood sugar (albeit with larger doses of medication) on a higher carb, lower fat diet. I'll be the first to admit that if I didn't have blood glucose issues I'd be eating more carbs. I truly feel that people should listen to their bodies and eat in a way that works best for them. From a personal standpoint, I tried introducing safe starches to my diet for several weeks after reading about the brilliant Paul Jaminet's Perfect Health Diet and found that I could only tolerate just under 1/2 cup of potato or rice; any more and my blood sugar was well above 140 at the one-hour mark. To me such a small amount just isn't worth the prep time! So these days the majority of my carbs are coming from all kinds of fruit as well as yogurt. My total carb intake for the day is about 90-100 grams (65-75 grams digestible or net carbs), and this works well for me. I'd like you to do what works best for you. If you feel great on a VLCKD and are able to achieve and maintain your goal weight by following this plan, that's wonderful. But please be aware that ketosis isn't necessary to achieve weight loss. As with any diet, it is calories in vs. calories out that determines the ultimate outcome on the scale. If you're wondering what my carbohydrate recommendations were for the article, as a general guideline I advised a starting point of about 85-110 grams of total carbohydrates (60-80 grams net carbs) per day using whole, unprocessed foods. (Interestingly, the Atkins website recommends 75+ net carbs daily, including grains, for lifetime maintenance). I know there will be many very-low-carb enthusiasts who think this is far too high, and I'm also expecting a backlash from other dietitians saying it's way too low, unsafe, unsustainable, lacking in nutrients, and, of course, too high in fat and protein. But I feel good about these recommendations given the research I've reviewed along with my own experience and that of others. You know the lyrics from that old song: You can't please everyone, so you better please yourself. References: 1. Zhou W, et al. The calorically restricted ketogenic diet, an effective alternative therapy for malignant brain cancer. Nutr Metab 2007; 4:5 2. Zhong Z, et al. A ketogenic diet as a potential novel therapeutic intervention in amyotrophic lateral sclerosis. BMC Neurosci 2006: 7:29 3. Johnson CS, et al.: Ketogenic low-carboydrate diets have no metabolic advantage over non-ketogenic low-carbohydate diets. Am J Clin Nutr 2006; 83:1055-1061 4. Martin CK, et al. Change in food cravings, food preferences, and appetite during a low-carbohydrate and low-fat diet. Obesity 2011; 19:1963-19704. 5. Bisschop PH, et al. Isocaloric carbohydrate deprivation induces protein catabolism despite a low T3-syndrome in healthy men. Clin Enocrinol 2001; 54:75-80
44 Comments
3/25/2012 02:29:25 am
Weight is a result, not a cause. Systemic inflammation is more important to consider for everyone and should be the primary focus if you are talking about a healthy diet. Are the extra carbs you are recommending promoting inflammation? If you are talking about grains, the answer is yes. If you are talking about starches, maybe not. So, eat the starch if you want to gain weight. Eat the grains if you want to age faster and develop heart disease, cancer, diabetes, Alzheimer's, and dementia.
Reply
Franziska
3/25/2012 03:03:51 am
Hi Tory,
Reply
3/25/2012 03:45:16 am
No doubt, we agree on a lot and talking about finer points here.
Hazel
3/3/2015 04:38:36 am
Tory Dutton: BRAVO
Reply
Franziska
3/25/2012 04:02:49 am
Thanks for clarifying, Tory. I'd like to age like Art Devaney as well :)
Reply
Franziska
3/25/2012 04:03:54 am
Thanks so much, Sam. Always appreciative of your feedback :)
Reply
One thing, though: I'm not sure we can conclude that ketogenic diets have no advantage over non-ketogenic low-carb diets for weight loss based on the results of the Johnson study. Both diets were restricted to ~1500 calories.
Reply
Franziska
3/25/2012 10:24:26 am
I agree, although for many sedentary women 1500 calories per day is a reasonable amount. I'd like to see longer-term studies as well.
Reply
3/25/2012 08:46:36 am
I am really glad that the ADA is recognizing low carb! I do about 60 grams a day that seems to work fine for me. I have talked to a few people that think just because they eat low carb, they can eat all the calories they wanted - then they didn't understand why they were gaining instead of losing weight.
Reply
Franziska
3/25/2012 10:34:20 am
I'm very happy about it too! The ADA has arranged for articles to be written about several different diets for diabetes: Mediterranean, vegan, and now low carb!
Reply
Great post! I am a dietitian too and agree with most of what to say, especially that there is NO one-size-fits-all approach and that everything needs to be individualized. I personally aim for 20-40 g of net carbs a day because I have PCOS and am very prone to weight gain and because of digestive issues that prevent me from tolerating starches and sugars. Thanks for your work!
Reply
Franziska
3/25/2012 09:00:00 pm
Thanks so much, Aglaee! PCOS and digestive issues can be very distressing and difficult to treat. I'm really glad that a VLCKD is working well for you, and I know the whole foods/Paleo aspect also plays a large role in improving your health. Best wishes for continued success :)
Reply
Gerri
3/26/2012 05:29:22 pm
Looking forward to your article. Hmmm, I may have to tone down my criticism of the ADA a bit. Perhaps the alternatives have become too well-known to be dismissed.
Reply
Franziska
3/26/2012 10:50:00 pm
Thank you, Gerri! Yes, the ADA is definitely recognizing that there are many different approaches to diabetes management, which is very encouraging.
Reply
3/26/2012 06:57:42 pm
Hi, Franziska. Well done post!
Reply
Franziska
3/26/2012 11:01:25 pm
Thanks so much, Steve! The article will be published online at
Reply
Jonathan Swaringen
8/23/2012 03:41:52 pm
I wonder how many people are doing The Rosedale Diet. I wonder if he would consider that number infinitesimally small. If my understanding of it is correct its VLCKD.
Reply
Hi Jonathan,
Much of what you write is conjecture and needs proper study. One issue you haven't touched on is sodium. LCHFers tend to be sodium deficient and need supplimentation, yet this goes against popular health culture. Is it a wonder fatigue and cravings set in?
Reply
Franziska
3/28/2012 01:47:18 am
Hii John,
Reply
John
8/10/2012 05:28:32 am
What is necessary for weight management is a lowering of insulin levels. If that means hitting a ketogenic state, so be it. Ketosis itself only means fat is being oxydized. It doesn't indicate what the source is, and it triggers no further benefits except for may better functioning brain and heart. Ketosis is merely a footprint in the sand. 3/28/2012 02:06:28 pm
Love the post, Franziska! I'm a big advocate of the ketogenic diet. Most people look at all of the foods you can't eat on the diet because they contain carbohydrates and think it is incredibly restrictive and hard to follow, but I have found that what the ketogenic diet does to my appetite alone makes it the easiest-to-follow diet I've ever tried!
Reply
Franziska
3/28/2012 11:59:38 pm
Thanks, Anthony! I'm glad you've found success on a ketogenic diet. Best of luck to you :)
Reply
I really appreciated both your thoughts and your citations. I'm preparing to do a short video on my new video blog regarding "miraculous" diets (I saw a magazine blaring, "Lose 10 Pounds Each Week - Better Than Liposuction".) Your informtion, insights, and references are of great value, as well as interest. Thanks for helping point me in the right direction.
Reply
Franziska
3/30/2012 10:37:35 am
Thanks so much, Bob! Great website, BTW. I love the footage of Admiral Stockdale: "Who am I? Why am I here?" ;)
Reply
Franziska,
Franziska
3/31/2012 12:10:46 am
I've bookmarked your blog and will definitely check back! Yes, inpatient dietitians spend most of their time on nutrition support, including TPN. I'm fortunate to be an outpatient dietitian who gets to spend the majority of the day providing nutrition ed to individuals and groups. Keep up the good work on your website and in your day job :)
Reply
Franziska,
Reply
Franziska
3/31/2012 10:19:14 pm
Sorry to hear that. It can be tricky working under a different service. Glad you'll be able to educate via your blog. Look forward to seeing future video posts!
Janknitz
4/26/2012 09:47:07 am
I hope you will share the responses and comments you get as the article is published, especially since we won't be able to access the article itself for sometime.
Reply
Franziska
4/26/2012 12:00:14 pm
Oh, I definitely will! The editors asked me to decrease the word count and number of references, as well as making some minor changes. Overall, they seemed happy with it, so that's good :)
Reply
I do much better on a predominantly ketogenic diet; a lifetime of migraines radically reduced as one benefit, and finally cured my insulin resistance. PhD nutritionist candidate Lucas Tafur lucastafur.com has some excellent posts on this subject.
Reply
Franziska
5/3/2012 01:00:08 am
Hi Nan,
Reply
Great post Franziska! Your right, it definitely varies form person to person and depends on how their own body reacts to various amounts of carbohydrates. However, i am a bodybuilder and i am a huge proponent of keto diets. It may be a little extreme and not appropriate for everyone. I personally only use it for short periods of time near the end of my cutting cycle. But, from my personal experience it has proven to be extremely effective at only targeting fat loss while allowing me to retain muscle mass.
Reply
Thanks so much, Darren! You probably also read my latest post (Part 2 of this article) in which I was much more enthusiastic about ketogenic diets. In fact, I've been eating 35-45 grams of carbs for the past 5 weeks or so and am very pleased with favorable effect this is having on my blood sugar. I'm so glad you've seen improvements in body composition with ketogenic eating. Nice blog, BTW -- glad you like Chipotle too! I have their chicken or barbacoa salad with plenty of guac about once a week :)
Reply
Glen
9/29/2012 08:55:16 am
I've been looking at your blog with interest, especially as I'm a low-carb diabetic myself.
Reply
Hi Glen,
Reply
Dub1045
4/30/2013 02:05:18 am
<140, is NOT NORMAL. Examine the works of Dr Bernstein who has worked to give us all a plan of having NORMAL Blood Sugars of <90.
Reply
4/30/2013 05:23:56 am
I realize Dr. Bernstein advocates normal BG in the 80s, but this is often not possible for people with T1, even those who strictly follow his program. I did say <140, and my own BG has not been >120 (at least whenever I measure) since September of last year. I'm happy with that and do not believe damage occurs with BG <120 from reading many studies and also observing patients in real life.
Dub1045
4/30/2013 02:01:08 am
Having been diag w T2 Diabetes about 18 months ago, I have joined the legions of Dr Bernstein's followers and am on a VLCHF diet. Having first started on Metformin, I managed my diet according to DR B and others and have managed to maintain an A1C of 5.4 for the past 9 months with NO MEDICATIONS.
Reply
4/30/2013 05:18:50 am
thanks for your comments and congratulations on your success with VLC! So glad you found Dr. Bernstein and have been able to discontinue metformin and maintain great BG control. Losing 40 lbs is terrific too. Glad you're enjoying the diet and it continues working so well for you.
Reply
GG
5/3/2016 02:25:09 pm
I know this is an old thread but just wanted to share that after decades of feeling unwell, putting on weight steadily, feeling really drop-dead tired, I've found my personal sweet-spot (pardon the pun) is about 80 carbs a day. Not ketosis, but long-term sustainable, happy and energetic lowish carb. I found ketosis hard and nearly as fatique-inducing as sugar. Maybe I didn't adjust well but after one month, I listened to my body rather thsn experts and now I feel amazing on low GI vegetables, and white meats, nuts, and occasional low GI fruit/berries. Too much fat makes me queasy though still, so it seems that high protein works for me. I'm losing weight steadily, and actually have the energy to exercise and the mental clarity to enjoy it.
Reply
5/3/2016 05:36:54 pm
Thanks for your comments and for sharing your experience, GG! I'm so glad you've found a carb level that works for you. I'm rarely in ketosis these days and eat very similarly to the way you do, and my total carb intake is around 70-80 grams as well, although digestible carbs below 50 grams. And like you, I feel great as well :) Best of luck, and keep up the fantastic work!
Reply
Your comment will be posted after it is approved.
Leave a Reply. |
Author
Franziska Spritzler, RD, CDE Categories
All
Archives
July 2019
|