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When I talk to people about my diabetes reversal journey and explain my ketogenic eating habits, they often tell me it's too hard and they can't do it.  I tell them that it's easy but they think it takes a lot of discipline.

I'm not kidding or exaggerating about the lack of difficulty.  The thing that might make it difficult is that it is a change from a person's routine and habits are hard to break.  Focusing on the objective and not the process helps to make it easy.

If you find that you've gradually been gaining weight over the years and all your previous diets have failed, it might be time to try a ketogenic diet.  Meta-analyses comparing low-carb diets to low-fat diets show a consistent pattern of better weight loss and improved metabolic markers.  Low-carb tends to increase LDL-cholesterol but LDL-C alone appears to be poor marker of cardiovascular health.  LDL-C is a good marker of lipid metabolism though.

As a previously overweight, Type 2 Diabetic, my objective is simply to become insulin sensitive.  Chronic diseases (obesity, Type 2 Diabetes, hypertension, cancer, osteoarthritis, dementia, PCOS, BHP, ED, etc) are manifestations of insulin resistance and is often the result of poor diet and lifestyle.  Insulin resistance is a result of the body becoming desensitized to increasingly higher levels of insulin over many years of abuse.  The obvious solution is to maintain a low level of insulin through a better diet and lifestyle.  Since the body produces insulin in response to carbohydrate consumption, a better diet for lower insulin levels is one that contains less carbohydrates and a very low carbohydrate diet is naturally ketogenic.

DISCLAIMER: My background is engineering and what I have written here is from my personal interest in staying healthy. If you disagree with any of it, let know what you feel is inaccurate and include some references so I can make corrections. This is a work in progress so check back often for updates as I continue to learn. CONSULT WITH YOUR DOCTOR BEFORE MAKING DIET AND LIFESTYLE CHANGES.

Ketogenic Breakfast

The body has two metabolic states: fed and fasted.  The fed state occurs when insulin levels are high while the fasted state occurs when insulin levels are low.  In the FED state, the body is in FAT STORAGE mode and "burns" predominately glucose.  In the FASTED state, the body is in FAT BURNING mode and burns predominately fat.  When insulin is high, it is difficult to lose weight and, conversely, it difficult to gain weight when insulin is low.

When the body is in the FASTED state, the liver makes glucose on demand (gluconeogenesis), which results in relatively low and stable blood sugar levels.  Interestingly, insulin lowers the metabolic rate and the difference between the fed and fasted states is about 300 kcalories/day - the equivalent of about 1 hour of normal walking (3.0 mph) for a 180 lb person.  A low insulin level puts the breakdown of fatty acids in the liver into overdrive, which results in so much acetyl coenzyme A (acetyl-CoA) production that it overwhelms the citrate cycle in the liver resulting in ketogenesis by forming one acetoacetate from two acetyl-CoA molecules. High rates of fat metabolism can result in up to 50% converted to ketone production.  High ketone levels also cause the mitochondria in both brown adipose tissue and white adipose tissue to become uncoupled so that they begin to generate heat like brown adipose tissue, which further increases energy consumption.  That might be a welcome side-effect if you've always got cold hands.

In other words, a ketogenic diet is simply one that maintains a low insulin level, which in turn naturally results in ketones as byproduct of fatty acid metabolism.

The three ketone bodies are acetoacetate (AcAc), beta-hydroxybutyrate (BHB or βHB, formed from AcAc), and acetone.  However, high serum ketone levels will be excreted in breath (as acetone) and urine (as acetoacetate)  "Ketone breath" (sweet or fruity scent) results when the unstable AcAc breaks down into acetone.  Ketone breath is noticeable initially as the body shifts to fat metabolism and becomes imperceptible as the body becomes accustomed to burning ketones.  Staying hydrated helps to minimize ketone breath.  Keto Crotch is not a thing and the rumour may have been started by a diet company or a pasta company, presumably to counter ketogenic diets.

Some in the medical community will warn about ketones possibly causing diabetic ketoacidosis (DKA) but this is nearly impossible to achieve through nutritional fasting because DKA also requires extremely high serum glucose levels  (over 13.8 mmol/L or 250 mg/dL) due to insufficient insulin production.  Not eating or avoiding carbohydrates generally results in normal glucose levels from gluconeogenesis.

The brain prefers ketones to glucose as its metabolic fuel and will cut back on glucose consumption as ketone levels increase.  Ketones are important metabolic fuels for other tissues, including heart and kidney.

The thing that makes adhering to a ketogenic diet so easy is that I don't count calories and I eat as much of whatever I want.  The thing about eating whatever I want is that I really like eating foods that don't raise my blood sugar.  That is, I love foods like eggs, bacon, cheese, prime rib, and chicken wings.  I don't eat them to the point I feel stuffed but instead I try to be mindful of when I'm satisfied - a small but very important distinction.  These foods are naturally satiating due to their high protein content and this is explained by the Protein Leverage Hypothesis.  I don't crave high-carb foods and sweets make me feel ill if eaten in excess.

Ben Bikman has the following whole food recommendations for a healthy diet:

  • Control Carbs (to maximum of 20 g/day)
  • Prioritize Protein (1.2-1.6 g/day per kg of body weight)
  • Fill with Fat (to satisfy your daily caloric requirement)

I find it easy to limit my carb intake to 20 g/day by eating vegetables (ie, the ones that grows above ground) and avoiding starchy foods (grain-based foods, potatoes, etc) and sugar.  See How much food is 20 or 50 grams of carbs?  I'm also careful to limit my consumption of fruits, which can also be loaded with sugar.  Throughout our 2.5 million years of human evolutionary history, fruit was only available for a short time while it was in season and helped us fatten up for the winter.  Fruit juices are especially bad because one glass contains the juice of several pieces of fruit without the fibre-containing and nutritionally more-complete solid parts. Don't drink your calories!

The protein recommendation is actually a lot of food and not that easy to achieve.  In my case, with my weight being about 88 kg, I would have to eat the equivalent of about 18-23 large eggs per day.  It's lot easier to do this with animal-sourced whole foods as plant-based whole foods would bring along a lot of carbs.  For human nutrition, there are essential proteins (histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine amino acids) and essential fats (omega-3 and omega-6 fatty acids) but there are NO essential carbohydrates.  The minimum daily requirement for carbohydrates is ZERO.  "Essential" means that you absolutely need it survive and your body cannot synthesize it from other nutrients.

Eating more than 1.6 g/kg of protein (more easily doable on a zero carb diet) appears to be beneficial although the upper limit in synthesizing muscle protein from dietary protein is about 0.24g/kg per meal for young men and about 0.39g/kg for older men.  It is difficult to store protein energy into fat tissue and the surplus ends up being used in gluconeogenesis.  Protein is the only macronutrient that contains nitrogen and Rabbit Starvation causes the body to self-limit protein consumption to about 35% of total energy intake.  I find that I'm usually satiated long before reaching the 1.2 to 1.6 g/kg recommendation.

Since animal-sourced whole food proteins always come with fat (fat contains 9 calories/gram compared with 4 calories/gram for carbohydrates and protein) in about a 1:1 ratio, it's easy to achieve the remaining fat recommendation.  Contrary to popular recommendations, saturated fat is good for you and it is the poly-unsaturated fats from vegetable oil (more accurately: industrial seed oils) that are unhealthy.  Seed oils were originally industrial lubricants until Proctor & Gamble figured out they could market cottonseed oil as Crisco shortening in 1911. Interestingly, cardio-vascular disease was rare prior to this time and seems to track closely with vegetable oil consumption.  The difference between beef tallow (stearic acid - saturated) and olive oil (oleic acid - mono-unsaturated) is one carbon double bond.

What I hear very often is:  I can't give up carbs.  There is no need to give them up entirely but, if you can't cut back on them, then you may very well have a carbohydrate addiction.  The really challenging part for many people is that carb addition is socially encouraged and your friends and relatives will often try to undermine your efforts.  If you were an alcoholic, I'm sure they wouldn't be forcing booze on you but they have no problem pushing pastries, snack foods, and soft drinks.

Bikman's recommendations for a low-carb, high-fat diet are essentially the opposite of the high-carb, low-fat diet recommended by Canada's Food Guide and the USDA's Dietary Guidelines for Americans..  The fact that the majority of the North American population is metabolically unhealthy should raise questions in your mind about whether government recommendations are grounded in science or influenced by special interests.

When I tell people that I'm doing intermittent fasting (aka time-restricted eating) and I try to only eat within a four-hour window every day, I often hear that they can't go that long without eating.  I eat when I'm hungry and don't when I'm not so I find intermittent fasting to be easy for the following reasons:

  • Maintaining low insulin turns on gluconeogenesis and this keeps my blood sugar very stable (no low blood sugar).
  • Low insulin turns on fat metabolism resulting in ketogenesis, and ketones tend to have an appetite suppression effect.
  • The hunger signal is affected by ghrelin, which peaks on a habitual schedule.  Continued intermittent fasting tends to reprogram the ghrelin schedule.
  • After breakfast (my first meal of the day), I'll be hungry again within a hour or two and have a bit more food.

I'm lucky enough to have a drug plan that includes Continuous Glucose Monitors, which is great tool to understand how diet and activity affect my blood sugar.  If its available, I highly recommend using a CGM to get instantaneous feedback on what's happening in the body.  CGMs measure interstitial fluid rather than blood so the absolute value of the reading is somewhat inaccurate.  Some things I've learned (in no particular order):

  • The Dawn Phenomenon happens every morning and what and when I eat the night before has a major impact on its magnitude and duration
  • The Dawn Phenomenon is more pronounced because of glucose intolerance rather than physiological insulin resistance.  I know this because eating carbs will cause my blood sugar to rise and then immediately fall to a normal (low and stable range of  4.5-5.5 mM / 81-99 mg/dl).
  • My blood sugar gradually decreases from its morning high to a normal range by early to mid afternoon.  I generally don't feel any hunger during this time although I might occasionally feel a low-grade hunger that goes away with activity.
  • It takes about 20 minutes of bike riding (a pace where I can feel a slight muscle burn) before I see a slight rise and then a drop in my blood sugar.  Continued hard riding results in normal blood sugar that may drop to the 4.0-4.5 mM (72-81 mg/dl) range.
  • Walking has a different effect on blood sugar.  Increasing my pace tends to increase my blood sugar and slowing tends to reduce it.
  • Regular exercise (biking, walking, etc) significantly improves metabolic markers (HbA1c, HDL-C, Triglycerides, Serum Creatinine, etc)
  • After eating a lot of carbs, I usually see my blood sugar rise very quickly and then fall just as fast.  Depending upon the carb load, my blood sugar might bottom out around 3.9 mM (70 mg/dl) for a short time before returning to a normal range.  I don't find low glucose to be noticeable, unlike in my pre-ketogenic time.
  • As I became more fat-adapted and only ate when I got hungry,  I found that I just kept deferring breakfast to a later time (1 hour later eventually became late afternoon).
  • I sleep better and have better morning blood sugar if I don't eat for couple of hours before bedtime
  • The longer I do intermittent fasting, the longer I can go without feeling hungry so don't expect to immediately be able to fast for 20 hours.
CGM After Breakfast

There are numerous long-term benefits to intermittent fasting and, since fasting lowers insulin with resulting fat metabolism, ketogenic diets naturally complement intermittent fasting.  Intermittent fasting with a ketogenic diet is lifestyle choice and should not be done as a short-term way of losing weight. Some of the benefits of intermittent fasting:

  • improved insulin sensitivity
  • prevention or reversal of low-grade inflammation
  • prevention or reversal of chronic diseases
  • improved longevity and healthspan
  • improved cognition through neurogenesis
  • less medication

Fasting can cause a loss in lean muscle tissue in addition to fat tissue.  Resistance training exercise (weight lifting) is highly anabolic and counteracts muscle loss.  Other physical activities are beneficial but not as effective.  Physcial activity has numerous metabolic benefits in addition to maintaining muscle mass.  The best exercise is the one you will do regularly.