Nutritional Ketosis, CGM Day 3: Now we are getting somewhere

As this blog series has rolled along, I’ve talked several times that it takes a few days to get into nutritional ketosis as you must first use up your excess stored glycogen. Yesterday, I started to see my numbers move a little more in the direction I’m wanting to go.

Here’s a quick rundown on my food for yesterday August 1st….

More fat is more satisfying

I incorporated more fats into my diet than I had been and more fiber as well. The total carbs are up quite a bit from prior days but the net carbs are still under 20 gms by a few points. My CGM for the day was super stable hovering around 70-80

Steady as she goes captain

Breakfast was another three egg omelette with sausage, ham, cheese, green peppers, onions, and mushrooms with three pieces of bacon. That was the majority of my carbs for the day at 13 net carbs.

Lunch was two roasted chicken thighs (4.5 ounces) and one serving of Avocado Mash from Good Foods. I really like this stuff. I get it at Costco and it offers me a way to eat avocados without trying to find the 3 1/2 minutes that they are actually ripe but not overripe and bruised. I added 2 ounces of macadamia nuts a little bit after lunch too for more fat. Net carbs for lunch was 5 gms. The nuts however added nearly 50 gms of fat. That was hugely satisfying.

Post work out ketosis

After lunch I worked out on the elliptical for about 45 minutes. It wasn’t a very hard work out but every little bit can help. Exercise can be a great way to reduce stress levels and build peace which as we all know by now is the fourth pillar of good health. Even though the workout wasn’t challenging, my post work out ketone level was up at 1.0 mmol/L

Brisket, avocado, and tomato.

Dinner was left over brisket, which when sauteed with ghee can be better than fresh out of the oven, an avocado and about 1/4 of a fresh tomato. A generous serving of Himalayan salt and this meal is hard to surpass in my opinion. Net carbs were 4.5 gms after subtracting out the 13.5 grams of fiber.

Moving on up after three days of keto nutrition

After my overnight fast of about 12 hours this morning’s ketone level remained as positive progress reaching 0.9 mmol/L. Not quite to the goal I’m aiming for but getting better.

I offer a couple take away points after three days of keto. First, eat more fat. It is very satisfying. Go read about Rabbit Starvation. Many times when patients tell me they are still hungry on a ketogenic or low carb diet they aren’t adding enough fats. They forget that it is a low carb, high fat diet not a low carb, high protein diet. Avocados, nuts, and olives are great sources for quality fat. Second, add more salt if you want it. Generally speaking, this diet reduces the amount of salt you retain and you diuresis more water. This helps reduce blood pressure for those wanting to come of medication. (Don’t do that without talking to your doctor first!) Imagine your food fixing your health more than your pills. Amazing! Lastly, don’t stress over exercise goals during the initiation phase of low carb. You probably won’t feel as energetic as normal and certain won’t feel as energetic as you will later on once you fat adapt.

Nutritional Ketosis, CGM Day 2

Wednesday was day two of documenting my journey into a nutritionally ketotic state of metabolism. As I mentioned yesterday, the body stores glucose which must be utilized prior to becoming fat adapted. Certain cellular machinery must be upregulated to mobilize fat from storage and allow it to enter the energy generating chemical pathways more efficiently. This process often takes about 72 hours on a low carb or ketogenic diet and can be accelerated by adding more glucose utilizing exercise along the way or starting from a low carb state of health. Full fat adaption takes nearly 6 to 12 weeks in my experience with patients when they first attempt to transition to a low carb lifestyle. Interestingly, I’ve never had a patient tell me they didn’t feel better having done so. Sure, some revert back to high carb diets for reasons similar to why it so hard to quit tobacco, alcohol, and recreational drugs; they’re addicting. No one goes back to a high carb diet once they truly experience a low carb diet because they felt better in their old way of life and enjoyed being 20 lbs heavier.

My dietary log for Wednesday started with the Kisner Omelette at Nick and J’s Cafe along with black coffee. That’s a hidden menu item created by one of my friends but unfortunately not named for him. It is a three egg omelette with onions, mushrooms, green peppers, tomatoes, cheese, diced ham, and sausage. It is amazingly good. I tend to have mine without the cheese and the carb content is about 11 gms net mostly due to the onions and mushrooms.

Lunch was a simple plate of pulled chicken breast from Archers with a little of their Moonshine Vinegar BBQ sauce and unsweetened tea. BBQ sauces are common culprits for added sugars especially in this area where tomato based sauces are preferred. The mustard based sauces are probably lower in carb content but the vinegar based sauces of North Carolina are likely the lowest. Each sauce can be pretty individualized so check out the labels if you get a chance or ask the cook for their opinion. Lunch was 0 gms of carbs.

When dinner time rolled around I was pretty excited to dig into my dry rub BBQ beef brisket that I was making at home. Over the last year, I have developed a recipe cooking brisket Sous Vide style for 36 hours that allows me to cook a large whole brisket separated into smaller 5-7 lb bags. Once cooked, I freeze what I’m not going to use right away. These can be thawed in the fridge for a day or two then finished in a 225 F convection oven for two hours. It has become one of my favorite meals and at $3.79/lb I can’t beat that price. It doesn’t hurt that my son loves this recipe and asks for it. It can be hard to feed a picky teenager and every little bit helps.

Prior to getting to eat my brisket I felt hungry, or rather, unsatisfied. I took that to indicate that I needed more fat intake. I think this relates to the Rabbit Starvation I mentioned yesterday. With 30-45 minutes left for my brisket to finish in the oven, I ate a cup of Fage whole fat (5%) Greek yogurt. This was 7 gms of carbs but 11 gms of fat and very satisfying. The 10 oz of brisket I ate later was 0 gms of carbs. It’s a moderately fatty portion of the brisket too.

For the day I had about 17 gms of net carbs with the majority of that being from the yogurt and the onions in the omelette. I’ve told my patients for years that once you get to about 20 gms of carbs or less per day that’s about as low as one can go. Even an egg as 0.7 gms of carbs and although many nutritional counters log meats like chicken and brisket at 0 gms of carbs per ounce that’s probably not true. When one eats 16-20 ounces of meat per day there is going to be some accumulation from these small amounts. However, the point isn’t to keep the carbs as low as possible or document every single quarter gram of carbs. The point is to keep the carbs low enough to keep my blood glucose stable and in the normal range.

The net effect of this day of Keto food was a pretty stable glucose reading. I call this a win. The lows, in this scenario, are inconsequential. I’ll talk more about them in another post.

So what was the result the following morning after a night of fasting? My serum ketone level, beta-hydroxybutarate to be precise, was 0.5 millimolar/L. That’s a 0.2 mmol/L increase from the prior morning. Remember that 0.5 mmol/L is the lowest end of the ketosis scale. My goal will be too get in the 1.5-2 mmol/L range.

Nutritional Ketosis CGM Experiment Day 1

During the last series on using a Freestyle Libre continuous glucose monitor (CGM) I documented the effects of a typical Western high carbohydrate diet on my blood sugars. Many of the meals I ate were obvious treats containing a lot of sugar, but many were just traditional foods, like toast, which still had a significant impact.

In this series I’m going to show the progression into nutritional ketosis (NK), that is, the process by which my body adapts to using ketones from fat breakdown as a major fuel source. The definition of nutritional ketosis is somewhat in flux but it’s generally accepted that NK begins around 0.5 millimolar of ketones as measured in the serum or blood. I will be using my KetoMojo ketone meter every day to show you the results I’m obtaining.

To start off this experiment, I was not particularly careful on my diet over the weekend. I ate quality food, mostly, but not very low carb.

Starting Tuesday, July 30th, I began to follow a ketogenic diet and will continue to strive to keep my carb intake 20 gms per day or less with a maximum of 50-60gms per day for the two week duration. These are recommendations I often give patients with type 2 diabetes and they are very successful in reversing that disease process. My default carb goal is about 75-100 gms per day. I’ve learned over the years that this is the level at which I feel really well and energetic. I focus on my carbs from whole foods such as fruit and sweet potatoes and allow variation from day to day depending on my activity level and taste buds. So a day of hiking might allow for more carbs after returning home while a day of office work I’d try to be more strict.

My diet log for yesterday is pretty simple. I ate three eggs fried in ghee and two pieces of Swaggerty sausage for breakfast along with my multiple cups of black coffee (3 gms of carbs). Lunch was with a friend at Archers BBQ consisting of 1/2 lb of pulled pork and unsweetened tea (0 gms of carbs). I know unsweet tea is sacrilege in the South but there’s a reason diabetes is so prevalent here too. Dinner was two roasted chicken thighs with sauteed onions and mushrooms (5 gms of carbs). My daughter and I then went to work out at VitalSigns which was 40 minutes on the elliptical and 25 minutes of resistance training with machines and body weight exercises. Trying to keep up with a cross country running Freshman during her workouts has left me sore many times this summer. After our work out, I made a protein powder shake about an hour before heading to bed (2 gms of carbs). That’s actually eating later in the night than I really want to, but I felt like the shake was a good idea. Part of the whole purpose of these meters is to allow someone to become more self-aware and be able to respond to their body’s needs instead of just following an regimented program that can’t adapt.

Nutritional profile for the day.
Note: carb count rounded in write up

The nutritional content of my day was very low at about 11 gms of carbs for the whole day. Protein was pretty close to my max goal. From prior personal experience, I don’t feel great when my protein intake gets too far above 160 gms for too long, but that can be dependent on my fat intake. This has been called rabbit starvation by Arctic explores like Vilhjalmur Stefansson due to eating the lean protein of rabbits without enough accompanying fat. However, I don’t want anyone to think that’s a prescriptive level, just my experience with my own diet.

So what was my result after one day of a ketogenic diet, a moderate intensity exercise for about an hour and fasting for 8-9 hours while asleep? Unsurprisingly, it was pretty normal. My ketones were still pretty low.

The human liver makes glucose continuously and can supply all the needs that the body has. Additionally, it stores about 2500 kcals of glucose as glycogen. That would take about 2-3 days of minimal activity to burn through or about 2-3 hours of intense activity. My one day of low carb intake and modest calorie expenditure is not enough to move me into nutritional ketosis. We’ll see what tomorrow holds.

CGM Experiment: What I learned as a non-diabetic from wearing a continuous glucose monitor – Lily Nichols RDN

Here is a great blog post from Lily Nichols, RDN author of Real Food for Pregnancy and Real Food for Gestational Diabetes and presenter at this years Low Carb Denver. Her presentation on low carb nutrition during pregnancy was a solidly scientific and engaging talk.

This post chronicles her time wearing the Freestyle Libre continuous glucose monitor and a good discussion on what ‘normal’ blood sugars should be for the non-diabetic.

I think there is a lot of good information here to consider for those of us who don’t have diabetes but want to understand the stress our body undergoes when we eat certain food.

I’ll be placing a new sensor on next week and blogging about my journey into nutritional ketosis and possibly the effects of fasting on my blood sugars. Stay tuned for that series although, sadly, there will be less cake involved compared to the first series.

Special thanks to my patient who found this article and shared it with me. One of the reasons I love my DPC job is I get to work with incredible people like you all. Patients who are engaged in their own health journey and challenge me too grow, learn, and apply are simply amazing.

Many non diabetics are wearing CGMs to better understand their blood sugar patterns. Here’s what I learned from wearing a continuous glucose monitor.
— Read on lilynicholsrdn.com/cgm-experiment-non-diabetic-continuous-glucose-monitor/

IDM: Women and Fasting: Top Tips for Women Going Through Menopause Part 2

I’ve seen this same observation time and time again. Since using a CGM with most of my patients I’ve begun noticing how often artificial sweeteners cause a reactionary drop in glucose. Presumably this is from the body producing insulin assuming that the sweet taste represents a usable sugar. Since there is no increase in blood stream sugars the net effect is a lowering. So where do sugars go when they leave the blood stream in that manner? They aren’t leaving the body. They aren’t being used as fuel during exercise. They get stored in a cell. It’s hard to lose weight when the body keeps storing glucose in the cells.

Women and Fasting: Top Tips for Women Going Through Menopause Part 2 – Intensive Dietary Management (IDM)
— Read on idmprogram.com/women-and-fasting-top-tips-for-women-going-through-menopause-part-2/

The Truth Behind What Intermittent Fasting Does to Your Body | Inverse

Studies show intermittent fasting can lead to weight loss, stabilized blood sugar, reduced inflammation, improvements in memory and stress resistance, slowed aging, longer lifespan, and blood sugar stabilization — all promising health benefits in return for considerable lifestyle changes.
— Read on www.inverse.com/article/57625-what-intermittent-fasting-actually-does-to-your-body

Decent article on fasting if you ignore the unsupported semi-vegan dietary recommendation. It’s amazing how one can write an entire article on lowering insulin production through fasting and then ignore that very concept when choosing food to eat. Plants are part of a good dietary plan but most plants are mostly carbohydrates. To lower insulin levels all the time, not just when not eating, you have to lower the carb intake. You can’t build your diet on a non-essential macronutrient and expect to stay healthy.

Maybe saturated fat doesn’t cause heart disease

Several recently published meta-analyses of observational studies and randomised controlled trials (RCTs) have found that total saturated fat is not associated with non-communicable diseases including coronary heart disease, cardiovascular disease, and all cause mortality

https://www.bmj.com/content/366/bmj.l4137

A recent report published in the British Medical Journal calls into question the validity of associating saturated fat intake with cardiovascular disease. Maybe the tide is changing.

bmj.l4137.full-1.pdf

CGM Day 9 & 10: Minor detour for ice cream

Did great yesterday until the end of the day when I succumbed to the siren call of ice cream after a very long day. The breakfast spike was due to my infatuation with blueberries.

Today was a new day though. I had my typical Wednesday breakfast at Nick and J’s Cafe of three eggs over well with bacon and black coffee. Then I met a friend for lunch at Dickies for 1/2lb of brisket. We celebrated his amazing success on his low carb/fasting journey which I hope he’ll share on this blog sometime soon.

This afternoon there was a handful of green grapes running out the door to go do yard work at the office.

Glory be to God, tomorrow is always a new day.

CGM Day 8: It takes one day

After last week’s daily deluge of carbs this week I plan to be much more moderate in my intake.

Today, breakfast was just a few scrambled eggs which had no impact. Lunch was a protein shake I like to make from About Time Protein powder with added MCT oil. Again there was no impact.

Dinner was the only meal that showed any increase in my blood sugar. It consisted of roasted chicken, fresh corn on the cob, steamed carrots, and some Colbyjack cheese. The elevation wasn’t enough to push me over 100mg/dL however.

So the lesson I’d like to impart here is that it only takes one day of change to see an impact on your health. Studies show that by the third meal of a low carb nutrition plan there is measurable improvement in someone’s insulin resistance. The time to change is right now.

I heard a proverb one time that said the best time to plant a tree is 20 years ago. The second best time is right now. Make your next meal the first meal of a new way of life. If you need help, call my office. That’s what I do.

CGM 6 & 7: The Coup De Grace

This weekend was my final two days on a high carb, ‘celebration food’, diet. For these days I planned several very high carb meals and they didn’t disappoint in their effect on my body.

On Saturday I worked Trinity’s Walk In Clinic at Fort Sanders West. Usually I bring a breakfast treat for the staff consisting of various low-carb yogurts with fruit and some decently low carb granola options. I decided to try out several of the types of yogurt individually to see their effects.

The first attempt was about 8:30am with Fage’s full fat yogurt. As you can see, one of the individual serving containers had no effect on my blood sugar. Listed as 6gm of carbs the actual amount is much less than that as the process of making yogurt utilizes some of the lactose through fermentation. It might be a good choice in the future for me for a low carb, low impact food.

The second attempt was an hour later with a blackberry Carb Master yogurt from Kroger. At 5gms of carbs and plenty of artificial sweeteners I was hopeful for a small impact. Again, there was no rise to my blood glucose but you can see a dip shortly there after. I’ve come to believe that the artificial sweeteners cause a release of insulin or a failure of glucagon which results in a low to often develop. I’ve seen this in several patients too. I will probably be limiting or avoiding these yogurts down the road. I’d rather have the plain full fat Fage.

Finally I got to the day’s glucose master challenge consisting of two apple fritters which I ate before I headed to Home Depot for some errands. I waited until after clinic was done as I knew it would slow my mental capacity and I didn’t want them to affect my clinical skills. No surprise my glucose spiked and I seriously contemplated laying down in the middle of Home Depot to take a nap. Not wanting to be cited for vagrancy I soldiered on and finished up.

After getting home, I spent several hours working outside in vigorous yard work involving moving rock, shoveling, and digging out a new flower bed. Those bouts of activity were associated with spikes in glucose too. I’ll be interested to see how my glucose responds to exercise when I’m fat adapted later this month. I’ve purposely not exercised in a formal way this past week to keep me as insulin resistance as possible. I’m looking forward to getting back to it.

On my final day, I wanted to go out with a bang so asked the family to go to Mimi’s after church. They were pretty surprised as I never want to go eat there as their low carb selection is very limited. This time that was the point. I had hoped for French Toast but since it contains cream cheese and orange marmalade, two things I really don’t like at all, I decided to try the chicken and waffles. Honestly, I’ve never had this before. I’ve eaten plenty of chicken and plenty of waffles but never on the same plate. I can see the appeal especially after pouring 2 ounces of maple syrup on everything.

The impact was amazing. Again, I felt like taking a nap and found it more difficult to think clearly. The carb count on this meal was incredible. The chicken and waffles is listed as 97 gms of carbs on Mimi’s nutrition website. When the syrup is added it totals 183 gms. Essentially the sugar in 2 oz of maple syrup is the same in all of the chicken and waffles! I couldn’t believe it. The effect lasted hours with multiple spikes. The maximum glucose achieved wasn’t especially high but the duration of effect was over several hours. The area under the curve was very large. That’s when the damage is done.

Later that night, I ate another couple burgers with buns similar to the ones earlier in the week. I wanted to see what affect they would have after such a high sugar load for lunch. Interestingly, it was blunted. Whereas they would typically cause an elevation, it was more restrained.

So as the week has progressed, I’ve learned and experienced many interesting things. I feel more sluggish and less mentally sharp in general and specifically after high carb meals. I’ve gained 3.5lbs of weight (in one week!). I’m more swollen and achy during the day. I don’t think I’m sleeping nearly as well as I usually do.

A single meal has a big impact. That impact is in both directions. A single bad meal causes stress for hours. A single good meal can really help you recover back to normal more quickly. Remember that each day is about each meal. Don’t stress too much ahead of time over the upcoming meals. Fight the battle in front of you and move on. Each day has enough trouble of it’s own.

What’s next? This week will be short as I’m headed out on vacation Saturday but I’ll be turning my attention to a good low carb, whole food recovery plan for the remaining days. I’ll be interested to see how quickly the weight will come off and I start to feel better. After vacation, I’ll use another sensor and document my progression into nutritional ketosis. I’ll be showing my ketone meter readings too.

I’d love to hear feedback from anyone about how this blog series has impacted your decision making process on food or your experiences with blood sugars. Please feel free to email me directly or post a comment publicly as you deem appropriate.