Tag Archives: ketosis

Low-Fat Versus Low-Carb Diet: DIETFITS Show Both Can Work If They Are “Healthy”

In the ongoing nutritional war between adherents of low-fat and low-carb diets, the skeptical cardiologist has generally weighed in on the side of lower carbs for weight loss and cardiovascular health.

I’ve questioned the vilification of saturated fat and emphasized the dangers of added sugar. I’ve even dabbled in nutritional ketosis.

The science in  nutrition is gradually advancing and the DIETFITS study recently published in JAMA is a welcome addition.

DIETFITS is a  really well done study which provides important insights into three huge questions about optimal diet:

  1. Should we choose a low-fat or a  low-carb diet for  weight loss and cardiovascular health?
  2. Do baseline insulin dynamics predict who will respond to low-fat versus low-carb diet?
  3. Can we predict who will respond to low-fat versus low-carb by genetic testing?

The Details Of DIETFITS

Stanford investigators recruited 609 San Francisco area individuals between the ages of 18 to 50 years with BMI of 28 to 40  and randomized them to a “healthy” low-fat diet or a “healthy” low-carb diet.

During the first 8 weeks of the study, low-fat participants were instructed to reduce fat consumption to <20 gm/ day while the low carb participants were instructed to reduce digestible carbohydrate to <20 gms/day.

Then individuals were allowed to add back fats or carbs back to their diets in increments of 5 to 15 g/d per week until “they reached the lowest level of intake they believed could be maintained indefinitely.”  Importantly no explicit instructions for energy restriction were given.

The “healthy” instructions for both groups were as follows

  1. maximize vegetable intake
  2. minimize intake of added sugar, refined flours and trans-fats
  3. focus on whole foods that are minimally processed, nutrient dense and prepared at home whenever possible

Dietfits Outcomes-Diet And Weight

Major findings

  1. Total energy intake was reduced by 500-600 kcal/d for both groups
  2. The low-fat vs the low-carb intake at 12 months was 48% versus 30% for carbs, 29 vs 43% for fat and 21 vs 23% for protein.
  3. Mean 12 months weight change was -5.3 kg for low-fat vs 6-6.0 kg for low-carb which was not significantly different
  4. There was no difference between groups in body fat percentage or waist circumference
  5. Both diets improved lipid profiles and lowered blood pressure, insulin and glucose levels
  6. LDL (bad cholesterol) declined more in the low-fat group whereas HDL (good cholesterol) increased more and triglycerides declined more in the low-carb group.

Thus both diets were successful for weight loss and both improved risk markers for cardiovascular disease after a year.

DIETFITS- Can Genes and Insulin resistance Predict Best Diet?

Surprisingly, the study found no significant diet-genotype interaction and no diet-insulin secretion interaction with weight loss.

This means that they could not predict (as many believed based on earlier studies) who will benefit from a low carb diet based on either currently available genetic testing or a generally accepted measure of insulin resistance.

As the authors point out, these findings “highlight the importance of conducting large, appropriately powered trials such as DIETFITS for validating early exploratory analyses.”

DIETFITS-Perspectives

As you can imagine this study has led to quite an uproar and backlash from dedicated combatants in the macronutrient wars.

A reasoned summary and response from Andreas Eenfeldt, a low carb proponent can be found on his excellent low carb/keto Diet Doctor site here.

Eenfeldt concludes

If I’m allowed to speculate, the reason that we did not see any major additional benefit from low carb in this study is that the groups ended up so similar when it came to bad carbs. The low-fat group ended up eating fewer carbs too (!) and significantly less sugar, while the low-carb group ended with a somewhat weak low-carb diet, reporting 130 grams of carbs per day.

Eenfeldt emphasizes that low-fat diets never “win” these macronutrient dietary skirmishes:

On the whole, this study adds to the 57 earlier studies (RCTs) comparing low carb and low fat for weight loss.

From a standing of 29 wins for low carb, zero for low fat and 28 draws, we now have 29 wins for low carb and 29 draws. The wins for low fat stay at zero.

Larry Husten at Cardiobrief.org in his analysis of the study quotes a number of experts including Gary Taubes, the low carb pioneering journalist

Taubes speculates “that the weight loss may have been similar not because any diet works if you stick with it and cut calories (one possible interpretation) but because of what these diets had in common — avoid sugar, refined grains, processed foods. Whether the low-carb arm would have done even better had Gardner kept their carbohydrates low is something this study can’t say. (And Ornish [low-fat diet proponent] would probably say the same thing about fat consumption.)”

The low-fat or vegan disciples seem to have had a muted response to this study. I can’t find anything from John McDougal , Dean Ornish, Caldwell Esselstyn or Joel Fuhrman.

Readers feel free to leave comments which  link to relevant analysis from the low-fat proponents.

Dietfits-Perspective Of The Participants

Julia Volluz at Vox wrote a fascinating piece recently which involved interviewing some of the participants in this study.

She points out that although the average DIETFITS participant lost over 10 pounds, “Some people lost more than 60 pounds, and others gained more than 20 during the year.”

LOW_FAT_LOW_CARBS_DIETS1__1_

She obtained permission from the lead author, Christopher Gardner  and interviewed  “Dawn, Denis, Elizabeth*, and Todd — two low-fat dieters and two low-carb dieters — about their experiences of succeeding or faltering in trying to slim down”

LOW_FAT_LOW_CARBS_DIETS1

I highly recommend reading the entire article for details but Volluz concludes

And that leads us to one of the burning mysteries of diets: how to explain why some people fail where others succeed — or the extreme variation in responses. Right now, science doesn’t have compelling answers, but the unifying theme from the four study participants should be instructive: The particulars of their diets — how many carbs or how much fat they were eating — were almost afterthoughts. Instead, it was their jobs, life circumstances, and where they lived that nudged them toward better health or crashing.

DIETFITS-Importance of “Healthy” Diet

Most likely the success of both of these diets is due to the instruction that both groups received on following a “healthy” diet. This guidance is remarkably similar to what I advocate and is something that combatants in the diet wars ranging from paleo to vegan can agree on.

The JAMA paper only provides the description I listed above but Volluz adds that participants were instructed to:

… focus on whole, real foods that were mostly prepared at home when possible, and specifically included as many vegetables as possible, every day … choose lean grass-fed and pasture-raised animal foods as well as sustainable fish ... eliminate, as much as possible, processed food products, including those with added sugars, refined white flour products, or trans-fats … prepare as much of their own food as possible. …

Indeed, if you want to see a very detailed description of the instructional process for participants check out the very detailed description of the methods here.

Yours in Health,

-ACP

N.B. I was searching for a reasoned response to this study from the low fat camp and to my surprise came across this fascinating video featuring the lead author of the study, Christopher Gardner, on (no fat/vegan) John McDougal’s YouTube site. Gardner is clearly on the side of sustainable, local , ethical food consumption but to his credit, his research , publications and comments on DIETFITS don’t reveal this.

For Whom The Ketosis Tolls

The skeptical cardiologist has gotten a lot of comments in the last week on both his “farewell to ketosis” post and a mysterious post consisting of simply “Br.”

On some level I feel like I’ve let down the low carb, high fat community by exiting ketoland prematurely. Certainly, the many ketophiles who pointed out the error of my path in ketoland have made excellent points.

One commenter wrote that side effects:

“can be mitigated or eliminated entirely by dramatically increasing your sodium intake (blasphemy, I know!), and decreasing your blood pressure medication (fun fact — that is one of the benefits of keto — normalizing things like blood pressure)”

Having read Atkins and other LCHF writers (including Peter Attia) pretty closely, I was aware of this and doubled or tripled my salt intake. I was dissolving salt into water and drinking multiple cups per day.  Also, if you read my posts on salt consumption, you’ll see that I don’t advocate across the board cuts in dietary salt, and thus I  commit dietary blasphemy with regularity.

In fact, I’ve written, with respect to salt loss by tennis players and by my hypertensive patients during the summer, the following:

“These variations in salt loss in the context of large variations in cardiovascular physiology and blood pressure regulation between individuals is further support for abandoning the ultra-low salt limits suggested by the AHA and the USDA.”

Also, I think dietary blood pressure lowering is awesome and as I mentioned, I cut back on my blood pressure meds and monitored my blood pressure regularly.

In response to another good point from a commenter on my statement that, “after a week of having to analyze in detail the carb or net carb content of everything that I consumed, I realized this was not something I wanted to do long term,” I can only say, “mea culpa.”

It could be the program you were attempting to do, but you’re overthinking it. Avoiding heavily processed foods (like Atkins bars) and favoring fatty meat and non-starchy vegetables will get you at least 80% of the way there without even really trying.

If/when I do it again, I’ll have a pretty instinctual understanding of what to do. It’s possible that my reasons for exiting ketoland relate more to a desire to consume proscribed items like beer, cocktails and large amounts of parsnips.

Another comment was “Since you wouldn’t run your car’s engine at hard and heavy exertion while you are in the middle of rebuilding it, why so would you expect to be able to continue to perform exercise at previous levels while you are rebuilding your body’s internal engine? Also, why are the only resources you referenced in this journey woefully outdated?”

I wouldn’t say I was engaging in hard and heavy exertion during my week in ketoland; walking a couple of miles to and from a restaurant or riding my bike at a moderate pace plus weights was the extent of it.  Perhaps that was too much to ask of my aging car’s engine as I retooled it’s fuel.

As to the references being outdated: William Banting writing in the 1700s is not recent enough for you?

Seriously, I was primarily delving into what Robert Atkins had promulgated and I utilized his Diet Revolution book,  first published in 1972; but I also referenced recent writings of Peter Attia and Andreas Eenfeldt.

Speaking of outdated references published in 1972 (and in a blatant attempt to reestablish my low carb cred), I highly recommend Paul Yudkin’s “Pure, White and Deadly.”  Yudkin, a British physician and nutritionist, concluded that increased sugar consumption was the major dietary cause of heart disease. Unfortunately, this scientific concept went up against the great and powerful Ancel Keys and the (now increasingly discredited) concept that dietary fat causes heart disease.

As Robert Lustig wrote in his introduction to the 2012 edition:

“The Pharisees of this nutritional holy war declared Keys the victor, Yudkin a heretic and a zealot, threw the now discredited Yudkin under the proverbial bus, and relegated his pivotal work to the dustbin of history, as this book went out of print and virtually disappeared from the scene. The propaganda of “low-fat” as the treatment for heart disease was perpetuated for the next thirty years. And the cluster of diseases (obesity, diabetes, hypertension, lipid problems, heart disease) collectively termed the “metabolic syndrome” increased in a parabolic fashion under the canopy of the sugar industry and their propaganda machine.
But good ideas die hard. Larger studies started to demonstrate that serum triglyceride levels correlated with heart disease, with sugar consumption being the primary driver. And there wasn’t one type of LDL, there were two: large buoyant LDL, driven by dietary fat, but which was neutral in terms of heart disease; and small dense LDL, driven by dietary carbohydrate, and which oxidizes quickly, driving atherosclerotic plaque formation (hardening of the arteries). The Atkins diet was now being taken seriously. Carbohydrates started to assume center stage in promoting metabolic disease, with sugar consumption implicated as the most notorious carbohydrate.”

The nutritional Holy Wars rage on. This omnivore, although an apostatic ketotic, genuflects before the wisdom of Yudkin.

UnPhariseeically Yours,

-ACP

Br

 

 

A Farewell to Ketosis: Banting, Dickens and The Roots of Atkins

The skeptical cardiologist spent an interesting week in ketoland, counting carbs, and turning ketostix purple,  but ultimately decided this was not a world he wanted to inhabit long term.

letter-on-corpulence-by-william-banting3During that week I paid 1.99$ to download William Banting’s “Letter on Corpulence”(available here for free.) Banting, writing in 1869, first popularized a low carb, high fat diet for obesity with this pamphlet. He starts it off with these words:

“OF all the parasites that affect humanity I do not know of, nor can I imagine, any more distressing than that of Obesity, and, having emerged from a very long probation in this affliction, I am desirous of circulating my humble knowledge and experience for the benefit of other sufferers, with an earnest hope that it may lead to the same comfort and happiness I now feel under the extraordinary change,—which might almost be termed miraculous had it not been accomplished by the most simple common-sense means.”

The pamphlet was enormously popular and sold over 60,000 copies. Banting donated his 225 £ of profit to various charities, including:

charles_dickens__2_
Charles Dickens, twice President of the Printer’s Pension Society and also did some writing. In the Pickwick Papers, he describes Joe, the Fat boy, who was perpetually falling asleep. Pickwickian Syndrome was the early medical term for what is now sleep apnea.

FatboyJoe“£ s.d.

To The Printers’ Pension Society, at the

Anniversary Dinner, in March, 1864,

per Chas. Dickens, Esq. .. .. 50 0 0″

 

 

In my last post, I closed with a paragraph  describing the benefits I had experienced of consuming a really high fat, very low carb diet: more energy, less sleep needed, asthma cured, wrinkled skin “melting away. This was supposed to be a humorous parody of how enthusiastic supporters of fad diets feel after they have jettisoned their bad eating habits but apparently most readers, unaware of my dry sense of humor (or perhaps not familiar with David Cronenberg’s The Fly) took this seriously.

Certainly, if I had felt significantly better on the Atkins diet I, like William Banting,  would still be on it. Alas, if anything, I felt worse.

My sleep was unaffected. Unllike, Robert Atkins, who noted his sleep requirements went from 8 hours a night to 5 hours a night, my sleep patterns were unchanged.

Energy levels in the morning were good but periodically in the afternoon, especially after even minor exertion but particularly after an intense workout, I would feel uncharacteristically exhausted.

Although my weight dropped 3-4 pounds this is typically what happens if I cut out alcohol from my diet for a week so it’s hard to say what the independent role of the extremely low carb intake and ketosis was.

My blood pressure dropped during the week and I had to cut back on my blood pressure medications to avoid dizziness. There were too many other variables occurring simultaneously that week (weight loss, lack of alcohol consumption) to know if this was independently associated with the ketogenic diet, however.

To be fair, supporters of ketogenic/Atkins diets warn us that during  the initial weeks, we may feel worse, experiencing the so-called “low carb flu.” To fully test it I should have stayed on it for 3-6 weeks and entered a maintenance phase in which I could have consumed more carbohydrates.

However, after a week of having to analyze in detail the carb or net carb content of everything that I consumed, I realized this was not something I wanted to do long term.

For the significantly obese like William Banting who  struggle to achieve weight loss the ketogenic/Atkins diet is likely to be a much better experience than for someone like me who is not overweight. Banting’s diet prior  to his “miraculous change” consisted primarily of bread, milk and beer and it is likely that cutting out the bread and beer alone would have had a dramatic effect on his weight and well-being.

My adventure in ketoland inspired me to update my dietary recommendations , the pdf of which is here (What Diet Is Best For Heart Health).

It would nice if we had some sort of genetic test that would tell us what diet is perfect for us. Unfortunately, until that is developed, trial and error is the only viable approach. Some, like William Banting, Robert Atkins and the  lady at zerocarbizen.org will thrive on very low carbs whereas others, like Dean Ornish and Nathan Pritikin prosper on a very low fat diet.

Most individuals will be served best by a diet of real, minimally processed food with lots of different vegetables growing both above and below ground and eaten in moderation.

Unbantingly Yours

-ACP

N.B. Here, in a nutshell, in Banting’s own words ,is the essence of the Banting diet:

“I never eat bread unless it is stale, cut thin, and well. toasted. I very seldom take any butter, certainly not a pound in a year. I seldom take milk (though that called so, in London, is probably misnamed), and I am quite sure that I do not drink a gallon of it in the whole year. I occasionally eat a potato with my dinner, possibly to the extent of 1 lb. per week. I spoke of sherry as very admissible, and I am glad of this opportunity to say, that I have since discovered it promoted acidity. Perhaps the best sherry I could procure was not the very best, but I found weak light claret, or brandy, gin, and whisky, with water, suited me better; and I have been led to believe that fruit, however ripe, does not suit me so well taken raw as when cooked, without sugar. I find that vegetables of all kinds, grown above ground, ripened to maturity and well boiled, are admirable; but I avoid all roots, as carrot, turnip, parsnip, and beet. ”

Excerpt From: William Banting. “Letter On Corpulence.” Foster, 2014. iBooks. https://itun.es/us/fOKP3.l

Adventures in Ketoland or How I learned To Love The Purple Stick

In the name of research and inspired by reading a biography of Robert Atkins, a few days ago the skeptical cardiologist embarked on an ultra low carb diet designed to put him in a state of ketosis.

IMG_6621Robert Atkins, the “cardiologist” who popularized the ultra low carbohydrate, high fat diet (LCHF) with his 1972 book “Dr. Atkins Diet Revolution,” admonished his patients: “Now remember, happiness is a purple stick!”

When the body shifts to utilizing fat for energy rather than glucose, the result is the production of ketone bodies which can be detected in the urine by use of a ketostick. When your urine turns the stick purple, you have become ketotic and have successfully kept your carbohydrate intake low.

Entering ketoland, as I like to term it, is not for the faint of heart. It requires a fanatical devotion to the LCHF pope, a steely determination, and meticulous monitoring of your food for anything that resembles a dreaded carb.

Nutritional Ketosis versus Diabetic Ketoacidosis

My first experience of ketosis was as a third year medical student on the vast, communal wards of St. Louis City Hospital. Here, the teeming indigents, the IV drug abusers and the criminals of the city came to share graciously their noxious diseases with we innocent disciples of Hippocrates.

Amongst the patients with AIDS and endocarditis, pheochromocytoma and Mallory-Weiss syndrome, there were many insulin-dependent diabetics who, for themselves, poorly did care or who had decompensated due to infection.

Emanating from their mouths and other orifices, I, not uncommonly,   noted a peculiar odor. It smelled like pear drops or ripe apple or perhaps, (had I been familiar with it at the time) nail polish remover, and was quite distinctive. Most of my fellow students could not smell it and relied on blood or urine tests to confirm what I had already detected-KETONES!

These diabetics had gone into diabetic ketoacidosis (DKA), a life-threatening complication and I was smelling acetoacetic acid.

Peter Attia has written eloquently and interestingly about the difference between DKA and nutritional ketosis here. You can only get the dangerous type of DKA if you are unable to produce insulin like type I diabetics.

Attia tells this embarrassing story:

“I remember exactly where I was sitting in a clinic at Johns Hopkins in 2002 explaining to (admonishing, really) a patient who was on the Atkins diet how harmful it was because of DKA.  I am so embarrassed by my complete stupidity and utter failure to pick up a single scientific article to fact check this dogma I was spewing to this poor patient. If you’re reading this, sir, please forgive me. You deserved a smarter doctor.

I’m pretty sure that,to this day, there are many doctors who only think of DKA when they hear the term ketosis.

Ketoland Deconstructed

The ketoland I have entered is not pathological: Atkins and, increasingly in the last decade, evidence-based and academic nutrition scientists, believe that ketosis may be a healthier state for our body to be in, free of wildly fluctuating,  inflammatory insulin cycles.

The cost of admission, however, is eschewing all bread, pasta, rice, potatoes, sugar-sweetened beverages, pastries, processed foods and, obviously, candy…that’s right out.

The tantalizing part of the diet is that it does not restrict your intake of fat in any way. In fact, to have your ticket punched into ketoland you must seek out fat in as pure a form as possible.

This morning, for example, I made myself a cup of coffee and adulterated it with heavy whipping cream (0 carbs, 50 calories of fat). Before leaving the house I took two boiled eggs and mixed them with mustard and safflower oil mayonnaise (30 grams of fat, no carbs) to eat later in the day.

I eat burgers, no fries, no buns, and I carry with me macadamia nuts, sunflower seeds, and almonds. I bought a huge jar of coconut oil and eat it by the teaspoon.

IMG_6615
An Atkins-aware dinner for me meant including my laptop with software to calculate the amount of carbohydrates per serving and measuring cups to precisely measure out the sour cream, guacamole and tex-mex low carb casserole portions. Kudos to the eternal fiancee’ for seemingly tolerating all this.

Ketoland is foreign territory for most of us. I had to enter foods into the myfitnesspal app to help me determine what the carbohydrate contents were.  I found myself paying close attention to portion size, not for the calories, but to help me better estimate how many carbs I was consuming.

For example, I thought that cauliflower would be a good snack, but 4 pieces of cauliflower cost me almost 5 carbs.

Happiness Is A Purple Stick

IMG_6616After 12 hours, during which I consumed 123 grams of fat, and only 26 grams of carbohydrates, my ketostick turned purplish.

What is it like in ketoland? Well, for one thing I only need 4 hours of sleep.  Asthma, which has plagued me all my life, is now nonexistent. Wrinkles have melted from my face, like wax from a burning candle. I have boundless energy. The best comparison I can come up with is the transformation Jeff Goldblum underwent in David Cronenberg’s (1986) The Fly. Come to think of it, he was probably also on a LCHF diet. Hopefully, I won’t experience his complete transformation.

****Warning. The above paragraph is an attempt at humor. None of it is true. Warning******

Seriously, I think it is too early to tell whether the tediousness of this diet will be worth it for me, but if I can last for a few weeks, I will have some good anecdotal short-term data to share with my patients on the diet’s effects on weight, energy, hunger, and personality.

Admonishingly Yours,

-ACP

If you are wondering why we make ketones, here’s a simple answer from Peter Attia.

For starters, it’s a vital evolutionary advantage.  Our brain can only function with glucose and ketones.  Since we can’t store more than about 24 hours worth of glucose, we would all die of hypoglycemia if ever forced to fast for more than 24 hours.  Fortunately, our liver can take fat and select amino acids (the building blocks of proteins) and turn them into ketones, first and foremost to feed our brains.  Hence, our body’s ability to produce ketones is required for basic survival .

If you’d like to watch a very well done 11 minute video on low carb high fat diets click here. You have to give an email address, which will send you Andreas Eenfeldt’s Diet Doctor updates. His site is very well done, free of ads and free of any industry influence.

You should be able to watch his diet revolution video, full of Swedish humor here.