Saturday, August 24, 2013

Deeper ketosis without protein restriction

In my last update, I had talked about the trouble I was having staying at the β-hydroxybutyrate level I wanted while eating to satiety. Not only was eating to hunger driving my ketone levels down, but higher ketone levels were correlating with irritability. Hunger and irritability are not my style. Besides, I have the intuition that something as healthy as ketosis should not entail health compromises. That's one reason I think the calorie restricted approach to ketogenic dieting, even in cancer, is likely to be wrong. More on that another day.

I am delighted to report that for a couple of weeks now I have consistently been in the 1.5 — 3.5 mmol/L range without restricting the quantity of my food, or even trying to be careful about not passing the satiety mark. Though I do, as always, emphasize fat in my foods, I am not limiting or even measuring my protein intake. My body's signals are clear and accurate and I don't agonize over whether this bite would be the line between enough and too much. There is no longer any correlation, as far as I've noticed, between irritability and higher ketone readings.

The trick seems to be exercise.

A few weeks ago, I made a few lifestyle changes at once. (I don't always have time for controls!)

  • I started getting up at 5:30 (amended to 5:00 several days later).
  • I gave up all but two small cups of coffee a day.
  • I started going to a weightlifting class at the local gym twice a week for an hour. I enjoy the 15 minute walk home.
  • I started running around the block once or twice a day in order to keep up with the 3-year-old riding his strider bike. That usually involves a little sprinting as we go the downhill direction, and walking or lightly jogging for the rest of the way. Some days I've also done a longer distance walk or bike ride.
There could be some effect of lower carbohydrate contribution from cream, or from something disruptive in the coffee itself. However, I feel fairly confident that the driving factor is the exercise.

Lyle McDonald: Effects of exercise on ketosis

Way back in 2002, I got my hands on a copy of Lyle McDonald's The Ketogenic Diet. It was out of print at the time, and was acquired for me magically by Zooko, in honour of our second anniversary. (Thank you, Sweetheart!) Back then, it was one of the few resources available for studying ketogenic physiology. Lyle McDonald's purpose in writing his book was to promote Cyclic Ketogenic Dieting for bodybuilding, and dispel myths associated with it. It is fairly technical, and well-referenced, but it does not presuppose detailed knowledge about specific biochemical pathways, so it's also accessible.

In it he shows that high intensity exercise (weight training or interval training) is a quick route to establishing ketosis, because it uses up glycogen stores. In the short term, however, high intensity exercise can decrease ketosis by inhibiting free fatty acid (FFA) release into the bloodstream. He also emphasizes the utility of low-intensity aerobic exercise, both for lowering glycogen and for increasing FFA for the liver to make ketones with. Low intensity aerobic exercise is very effective in establishing ketosis, but it takes a long time to deplete glycogen that way.

His bottom line recommendation, then, for establishing ketosis quickly, is to do a high intensity workout to deplete glycogen, followed by 10-15 minutes of low intensity aerobics.

This is precisely what I've been doing every day! Lifting and then walking home, sprinting and then a fast walk around the block, or a long distance, low intensity walk or ride, all qualify as efficient ketosis enhancement.

This is working for me without recourse to hunger-inducing protein restriction.

Fat loss without muscle gain necessarily implies a caloric deficit even though caloric deficit does not necessarily result in fat loss. Analogously, inducing ketosis through exercise and carbohydrate restriction may well be resulting in a naturally lower protein intake for me. I don't really care that much. I'm eating as much as feels good to me of foods that make me well, and it is no longer interfering with my health goal of being in ketosis.

Whether and to what degree this affects my body composition is not yet clear. My clothes are fitting better. I guess I ought to buy a scale.

23 comments:

  1. Thanks for posting this, Amber. As you know, I tried a couple times to get into ketosis as registered on a blood meter, and had to restrict not just protein, but overall food intake, in order to get past "trace." This was very difficult to sustain, just as you say.

    However, I've gotten so used to not "needing" to exercise for weight maintenance that I think I've overlooked its other health benefits, too. I'm excited to give this another try. I'm so glad you kept at it!

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  2. Good point about the exercise, one tends to think of ketosis in terms of diet only. Perhaps my ketosis-resistance is due to not working out lately.

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  3. As low carbers, I think we're quite used to the idea that exercise doesn't work for weight loss, because it doesn't usually on its own, and because it's all tied up in the calories-in/calories-out nonsense. In contrast, diet alone is usually powerful enough. I didn't exercise much during the time that I lost the initial 50 pounds.

    But if your diet isn't undoing them, the hormonal effects of exercise can be synergistic.

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  4. This is very exciting! And I am very happy for you.And I suspect you are very much on to something that I think has been a huge factor for me. Thanks for sharing your experience. I think it has the potential to help many. And you are doing very reasonable and do-albe excercise that is long-term sustainable and won't burn you out. This is big, big, big in my book. YAY!

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    1. Thank you for the encouragement, mem! I'm also very happy about it.

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  5. I think reducing coffee could be a significant contributor as well. Caffeine can prevent your blood sugar from going lower and there seems to be a correlation between blood sugar levels and ketones production.

    "Another student, Ivan Urits, was unable to lower his glucose to the metabolic range despite 6 days of fasting and elevated ketone levels (2– 3 mmol). His glucose was reduced only to 68 mg/ dl during the fast. It turned out that Ivan was drinking caffeinated black coffee, rather than drinking only water during the fast. Caffeine can prevent glucose levels from entering the therapeutic zone necessary to target the energy metabolism of tumor cells. Herbert Shelton argues against coffee consumption during fasting [51]. It would be better to consume calorie-free decaffeinated beverages than caffeinated beverages. "
    http://cassiopaea.org/forum/index.php?topic=29102.0

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  6. Hi,

    My name is Lazaro and I'm a member of the Israeli zero-carbs facebook group. I first want to thank you for both your blogs ( this one and Ketotic ) - there are a few blogs around on this subject and I think these two are the best - I hope you keep writing :)
    I wanted to ask a question regarding having to restrict eating in order to stay in ketosis - in the Ketotic blog you said gluconeogenesis isn't dependent on protein intake, meaning ( if I got it right ) that as long as you eat fat and protein, you should stay in ketosis no matter how much you eat. In this post you said that you had to restrict protein intake ( or exercise ) in order to stay in deep ketosis - this seems like a contradiction.

    Thanks again for all the clear and concise info

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    1. Hi Lazaro. Thank you so much for the encouragement, and for the question.

      It seems pretty clear based on anecdote and on clinical claims that protein has to be below some threshold for ketogenesis to continue all else equal (except the effects of fat intake, calorie intake, amino acid profile, and type of fat also matter!). What I've tried to show in those posts on ketotic.org is that the mechanism for this doesn't seem to be that excess protein just gets automatically turned into glucose by GNG.

      The studies I looked at made it seem unlikely that the mere presence of protein increases GNG. It also looks like the insulin-to-glucagon ratio, which many believe is a major GNG rate controller doesn't change on ingestion of protein.

      One possibility for what is happening is that cells start taking up amino acids and that competes with glucose uptake. Then the rate of glucose going out of the blood slows down, which raises blood sugar if the rate of incoming glucose is the same. Then the higher blood sugar signals ketosis to slow down. This explanation does not require more glucose coming into the blood. But this is just a guess. It could be anything.

      I tried to clarify this in the following post and in Protein, Gluconeogenesis, and Blood Sugar, and Protein, Ketogenesis, and Glucose Oxidation.

      However, I realize now that these subsequent articles aren't linked to from the original, and they should be.

      -Amber

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  7. I have done a keto diet in several spurts over the past year+, and tested my blood ketones daily while doing it, and here's what I have found - even just 15 minutes of mild exercise (walking, leisurely bicycling) raises ketone levels noticeably (by 1-1.5mM) over pre-exercise level, and strenuous exercise (mountain hikes, running, strength training/weight lifting) raises it slightly more than that (an additional 0.5mM, on average). I also often do a type of IF with only Bulletproof Coffee (coffee + 2-3T pasture-raised butter like KerryGold + 1T MCT oil, blended) or butter tea (black tea with 1-2T butter, blended) in the morning, and sometimes again midday. The days when I have done both the BP coffee and exercise, my ketones have been in the 5-6mM range, and I have felt like absolute dynamite, as long as I ate a solid dinner (meaning including some protein) rather than continuing the 100% fat fast.

    I have found that I must keep my fat intake >75% to stay in ketosis, exercise or no exercise, and 80-85% is optimal for me (good energy, mental clarity, fat burning, ketones in the 1-5mM range). Once I'm in the 80-85% range, then exercise bumps up the ketones more.

    I have experimented with 85-100% fat regimens, and have found that the downsides outweigh the positives for me (fat burning is accelerated, but hunger is a noticeable irritant at that macronutrient ratio, and energy is not as good). Of course, this could be due to the release of stored toxins in fat cells, and thus would improve over time. But, we do need some protein, just not a LOT.

    Note that for me, reaching 5+mM of blood ketones was predicated on ingesting MCT oil AND exercising in the same day. Each by itself was helpful, but there was a compounding effect of doing them together, for me.

    I wonder what effect getting (or not getting) good quality sleep has on ketosis. Thoughts, anyone?

    Onward with the experimenting! :-)

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    1. Hi, Emily. Thanks for your input!

      While it's true that exercise raises ketones at the time (and I'm sure that's valuable), I'm more looking for the effect on ketones the next morning. I want to affect the baseline levels that I sleep and wake with.

      My fat intake is pretty high, and I guess it's been 3 or 4 years now that I've been blending fat (with varying percentage of MCT) into my coffee. Most days I don't eat food until after noon. So, I'm already doing those things, and I've only measured 5+mmols in the morning once or twice in history!

      I've experimented in the past with increasing fat, but it did not cause me to lose weight. For one thing, it didn't make me less hungry for protein. I am convinced that hunger is an indication that you are either losing lean mass, or not burning enough fat to meet your energy needs or both. Therefore I consider it counterproductive. So keeping calories the same but reducing the percentage of fat isn't an acceptable strategy for me. It sounds like it is the same for you -- you said that 85-100% fat makes you hungry, which I think implies you are keeping calories constant -- otherwise you would just eat more, right?

      The synergistic effect you mention is interesting. There is a point at which I don't necessarily consider higher better, though. Not because I don't think using more ketones is better -- I suspect it is! -- but because higher levels in the blood could simply indicate that you are making more than you are using. The blood level is a proxy for use, and it might be a worse proxy after a certain threshold.

      I got this idea from Zooko, who pointed out that just like in the case with blood sugar (which we argued can't tell you how much glucose you are making or using) the blood level can't tell you the rates of production or uptake. He was offering an explanation for why seizure reduction doesn't correspond as cleanly to BOHB levels as one might expect.

      So I'm pretty cool with just being consistently above 1.5 That's where I subjectively start to feel really good.

      The sleep question is interesting. It sounds challenging to answer. I guess you'd have to persistently deprive sleep and see if ketones are lower? It could interact with activity levels and be hard to tease apart. There is some literature showing that ketosis improves sleep quality, though. That's an easier direction to test.

      Cheers to experimentation! ☺

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    2. I have heard Nora Gedgaudas and others say that insufficient sleep, sleep apnea, and stress in general can all raise blood glucose and lower blood ketone levels.

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    3. I have also heard Stephen Phinney say that more ketones above 3.0 is not necessarily better. It is not necessarily detrimental either. It is, however, an indication that you may not be burning ketones efficiently.

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    4. Finally, intermittent fasting definitely raises ketone levels for me.

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  8. Hello Amber,

    I'm curious to learn more about the relationship of fasting, and nutritional ketosis (or normal baseline endogenous fat-to-energy conversion, and ketone-dependent energy production). I can find much of the biochemistry discussed online (notably at Peter Attia's Eating Academy), and I'm tinkering (n=1) to find out, but I have not found answers to a few questions that have arisen.

    If fasting eventually raises endogenous b-ohb production, how long a fast does it take before we are in ketosis? Or, is overnight fasting, even for 14+ hours but for fewer than 24 hours, normally insufficient to increase ketone-body production above the ketosis threshold?

    And does the answer depend on individual variability in energy expenditure (i.e. as your post implies, the higher energy demand raises baseline or fasting b-ohb levels)?

    You mention in your response (immediately above) that you think that "blood level [of ketones] is a proxy for use, and it might be a worse proxy after a certain threshold." Ideally we should somehow directly measure the liver for ketone output. I recognize that you're referring to the higher (possibly surplus) levels of blood ketones, but what about at the minimum end? You, Phinney, Volek, and Attia (et al) refer to 0.5mmol of b-ohb as the minimum threshold for *nutritional* ketosis. Is that (simply) enough of a measure to establish ketosis?

    Could it be that circulating b-ohb (in the serum), if "a proxy for use", could also be lower than actual b-ohb (or other) ketone production and conversion to energy? Or, could one be *in ketosis* before circulating serum b-ohb levels rise to 0.5mmol? Or does that make no sense, according to the basic biochemical engineering of the body?

    It makes sense to me that if say one drinks coffee with fat (added butter, whatever) as *breakfast*--and I assume that any subsequent rise in serum b-ohb directly results from the ingestion of fat--that does in fact break the fast. But is there a kickstart effect, so that once the exogenous fat-to-ketone source is exhausted, the metabolism restarts or begins endogenous production, perhaps, even, more efficiently, until lunch time anyway? (Or, is the tablespoon of butter for breakfast enough to last through lunchtime?)

    In short, in either scenario (with or without butter-in-coffee for breakfast), could endogenous ketosis actually happen and be undetectable via serum b-ohb testing?

    And how are things going for you, a few months later?

    Thank you!

    Patrick

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    1. Hi Patrick. Thanks for your stimulating questions.

      I intend to write a post about fasting. I don't know the average time to therapeutic levels of ketosis off the top of my head, but it is on the order of a couple of days, though of course there will be some variation.

      When I say blood levels are only an approximation of use, I mean of conversion to energy, not production.

      By "endogenous ketosis" do you mean coming from your fat stores? There is always some ketone production going on, but there is a point at which it starts to be preferred. We go into this a bit in the keto-adaptation article.

      Daily high intensity exercise is not sustainable for me, so this idea is not a full solution for me. However, I have been experimenting with some other ideas, too, so I'll be posting about those soon.

      Thanks for the encouragement.

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  9. Hi Amber
    I have just started on NK. I have a history of IBS and am restricting all vegetables and seem to do quite well restricting all FODMAPs. So far so good without veg. I have bought a blood glucose meter and after a week my BGL is around 4.5mMol and ketones were 0.8 mMol the last two days. I have been finding that while I'm not particularly hungry I do have to try really hard to keep my protein intake down. I'm just wondering after reading your post whether I need to worry about keeping track of it?? I am eating quite a lot of dairy at the mo but reckon I'm sensitive to that too. Once again if I remove it my protein levels seem to be too high. I don't do well with coconut so don't eat that and mostly cook with tallow or butter. Do you include the fat you cook with as part of your fat intake? My carb intake mainly comes from berries, about 20g per day and the only thing I drink other than water is herbal tea, raspberry leaf or rooibos however I'm wondering if I should even give the tea a miss since I have gut sensitivities that I can't quite get on top of. I'm keen to try an all meat diet to see if that helps. I am 164cm and approx 66kg ( I don't own scales). I'm usually quite active, some walking and body weight exercises at home but have an acute back injury at the mo. My chiro tells me healing will be around 6 weeks before I can get back to any body weight stuff but should be back walking in about a week I hope. Just wondering if you can comment on my situation. Thanks Mel.

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    1. You might want to try eliminating the berries. Pretty much all plant foods are high in salicylates, esp. berries. I have recently discovered this for myself. Salicylates interfer with mitochondrial function and most people with illnesses already have mitochondrial dysfunction. For me, they cause generalized inflammation and migraine headaches.

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  10. Hi, Mel. What happens if you take out berries and dairy for a couple of weeks?

    Berries are high in phenols, which some people are sensitive to.

    I recently quit dairy, and I think it has had a significant effect on my appetite for protein. That surprised me, because I've had some dairy most days all through these years. At some point a couple of years ago I discovered lattes made with heavy cream and butter, and I suspect that going from a little cream in my coffee to a cup or more a day may have been a move for the worse, even though it is mostly fat and the carb content isn't very high.

    I haven't had to deal with gut issues, thankfully; I've never suffered gas or bloating or abdominal pain or anything like that. So if I do have problem with dairy, I am more likely to suspect an insulinogenic effect as the mediating factor than a sensitivity. While cream does not give me frank cravings, yoghurt absolutely does, even at the tablespoon level, and even if it is made from cream, and I cannot even have it in the house.

    I don't have ketone strips right now, so I haven't yet verified whether ditching cream has made a difference in blood ketones. I plan to invest in some soon and figure that out, and I'll certainly post about that when I do.

    I do eat the fat I cook with, and sometimes add extra bacon drippings, too.

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    1. I have been experimenting with a lactose-free sour cream which I adore. The fact that I adore it is probably the tip off right there...LOL! Even with only 1 gram of carb per ounce, it does seem to make me hungry for more. I can easily eat 6 oz. and would like to eat more. It like the best dessert in the world. Haha! I think I am going to save it for making a liver pâté to hide the taste of the liver. I don't seem to experience any sort of "stop" sensation with it. Very interesting. This goes along with Dr. H.L. Newbold's experience in working with extremely carb sensitive folks as he details in his classic book "The Type A/Type B Weight Loss Diet" in which he considers all dairy products to be "new foods" in the human diet and just as problematic as grains for some when it comes to producing hunger.

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  11. Thanks heaps for your reply Amber. I think you've hit the nail on the head with the "craving" word!! That is why I'm hanging onto the berries and dairy!! Yes, especially the creamy Greek yogurt! Most days I'll have one or the other, berries or Greek yogurt! Its definitely worth taking them out for a couple of weeks to see how I feel. Might take me a couple of days to work up to it though! :)

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  12. Amber - can you please write what you think the connection is between higher ketone levels and irritability ? I've been experiencing the same thing and have no idea what the cause is. Isn't ketosis supposed to reduce anxiety/irritability ? Maybe it is the black coffee ? Maybe it is just having "too much energy" one has to do something with ?

    Thanks in advance for your answer - your blogs are great :-)

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    1. Hi, Robert,

      Yes, I think it just comes down to higher ketone levels resulting from not eating enough, and irritability coming from not eating enough. That is, in this case there is a common cause, rather than one causing the other.

      Keto itself is great for my mood, but when it is higher *because* of my protein being too low, then there are other, bad consequences. I think this is thematic. I sometimes see people complaining about keto giving them symptoms that are clearly symptoms of caloric restriction. They aren't eating enough, plain and simple.

      Thank you for the encouragement.

      —Amber

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