‘All natural, 100% fruit juice with no added sugar’ will still kill you.

As a kid, I grew up drinking orange juice from time to time. I always found it one of the most refreshing drinks when I was really thirsty. As I learned more about carbohydrates and their impact on my body, I came to realize that the fast acting nature of a fruit juice drink could be harmful. Now to be fair from the onset, I teach my patients an appropriately low enough carb, whole food nutritional plan that, if followed from an early age, might include naturally occurring fruit like an orange. I’m not anti-fruit or even anti-carb as it is a complex question to answer. I even spent about 30 minutes one afternoon in the middle of Food City answering my then 9 year old daughter’s simple question “Is orange juice healthy?” That being said, I spent so many years of my life eating Poptarts and Crunch Berries that I must be more deliberate about my choices now as a consequence. What is the perfect human diet? That may be different than the diet a particular patient may need to correct the metabolic damage done. The principles remain the same but the details might be different.

In my case, I’ve written before that during my four years of medical residency I was on call every 3rd or 4th night spending about 36 hours straight in the hospital. Making a meager salary, I depended on the meal stipend of $9 per 36 hour shift to get me through those long stints. One wilted, slightly too warm salad was $8.50 and only available at lunch time. However, a package of frosted brown sugar and cinnamon Poptarts was $0.85 all night long. I ‘needed’ the emotional reward anyway. It was easy to justify.

8 ounces of all natural deliciousness?

This morning I decided to try orange juice again since I’m wearing my Freestyle Libre continuous glucose monitor. In a fasted state, I had 8 ounces of all natural, 100% fruit juice with no added sugar orange juice. Pulp free, of course, because I’m not a sociopath. So, is orange juice healthy?

As bad as pancakes

You can see from my monitor report how well controlled my glucose was overnight while fasted. The slight waver noted just before 6am is due to the catecholamine surge that occurs when the alarm clock goes off and I get out of bed. My peak of 160 mg/dL took 31 minutes to occur on the meter which means it was even faster in my blood stream. I might as well be mainlining a glucose solution. This is like going to the beach at noon in the summer time and putting on tan amplifier oil.

The beauty of the CGM is that it automatically tracks the progress of my body sorting and dealing with the excess sugar. It took about 1.5 hours for my system to normalize. During the time of my sugar high I was meeting with some friends for breakfast and I had a hard time concentrating on the topic at hand. Literally, my brain was so foggy that I struggled to remember facts that should have been immediately present on my mind. It was frustrating to say the least. Even now as I write this over 3 hours later I’m still not as clear as I was yesterday when I was still in nutritional ketosis.

Back to normal? Only by the number

So what’s your story? What foods have you had that impacted your glucose numbers? Are there foods you have enjoyed by tradition, culture, or habit that you now realize shouldn’t be a part of your diet? What’s been the impact? I’d love to hear your stories and the lessons you’ve learned. And, if you don’t yet have a CGM, ask your doctor for one. Don’t take ‘no’ for an answer. If they tell you that you don’t qualify for one politely tell them “Well, I have $35 in my pocket and I’m a responsible human interested in my own health, so, yes, I do qualify.”

Mealtime patterns

Posted below are two reports generated from the Freestyle Libre LibreView website. They show the average relative change in my blood glucose with each meal of the day. The first report was during the high carb, standard American diet experiment in July. The second report is from the nutritional ketosis diet I just blogged about and am still following. I think it is readily apparent the differences. In the high carb diet I would jump 20-30 mg/dL every time I ate and I averaged 30-80 gms of carbs per meal at least. With nutritional ketosis the glucose changed less than 10 mg/dL with each meal and I only averaged 6gms of carbs per meal.

Nutritional Ketosis and Intermittent Fasting

Over the last week I’ve documented my progress into nutritional ketosis through a ketogenic diet. Yesterday, I added intermittent fasting to that process. Here are the results.

As most of you know, I have advocated for low carb high fat nutrition to reverse metabolic disease since I began practicing it myself in 1999. My understanding of this powerful tool has grown both with my personal experience of it and with the growing body of literature helping to explain the nuances we should all understand. Over the last three years intermittent fasting (IF) has come into it’s own in large part due to the influence of Jason Fung, MD author of The Obesity Code and The Diabetes Code, both books I highly recommend to my patients. I have adopted IF as a personal routine over the last year and have found it extraordinarily powerful at improving my health and well-being.

There are many different ways to undertake fasting ranging from time restricted eating (TRE) to prolonged fasts. TRE is simply not eating for about 12 hours in every 24 hour cycle such as not eating after dinner until breakfast the next day roughly 12 hours apart (8pm to 8am). Most studies don’t consider this true fasting as many of the genes and benefits of fasting are not measurable until one reaches 14-16 hours of fasting.

Intermittent fasting therefore is usually anything lasting 16 hours or longer with the remaining hours used as an opportunity to feed. A 16:8 protocol is nothing after dinner at 8pm until noon the next day. A 20:4 protocol is nothing between 8pm and 4pm the next day. I recommend many of my patients undertake a 24 hour fast weekly or every fourth day depending on the goal. Again, I stress, please don’t undertake this without talking to me first as many times patients need their medications reduced or altered to avoid being over treated during the fasted state.

Yesterday I undertook a 24 hour fast which ended up lasting 27 hours due to the timing of my dinner meals on Monday and Tuesday. Monday night I ate a quick meal of roasted chicken, blueberries, and macadamia nuts then went to exercise around 5:30pm. I didn’t eat again until Tuesday night at 8:30pm. Tuesday’s dinner of 1/2 of chicken, an avocado, and cheese was 5 net carbs.

Throughout the day I followed my glucose levels on my Libre and my blood ketone levels on my KetoMojo meter. As you can see from the Libre readings below, my glucose levels were exceedingly stable and slowly declined throughout the day to a nadir of about 69 mg/dL right before dinner. My meal didn’t budge that number at all.

The ketone readings steadily climbed to some very nice levels throughout the day and have stayed higher than last week even after I’ve eaten several times today. Starting out the day at 1.0 mmol/L they climbed to 1.7 mmol/L by lunch time, 2.7 mmol/L by the end of work, and 3.1 mmol/L by the time I broke the fast at dinner.

Beneficial ketone zones after an overnight fast should be around 0.5 mmol/L or higher. They are are optimal around 1.5-2 mmol/L while eating a long term ketogenic diet. After a prolonged fast they can be around 3-5 mmol/L.

When I fast I tend to feel better and better as the day progresses. The initial hours can be challenging but as the ketones develop the desire for food all but fades to zero and hunger is non-existent. I really enjoy that freedom. The clarity of thought and presence of mind that comes in this state is one of the main benefits I desire from fasting. It brings me back to it again and again and I find myself looking forward to the next day of fasting.

If you’re interested in learning how to use nutritional ketosis, intermittent fasting, or a continuous glucose monitor for its health benefits give me a call. We’ll walk through the process together to ensure your success and safety.

Nutritional Ketosis, Days 5 & 6

I didn’t get a chance to update the daily posts yesterday as the start of school, high school sports practice, and school supply shopping made for a long day. Regardless, the data hasn’t changed much. I had about 29 net carbs Sunday and 22 net carbs Monday.

This produced very stable blood sugar results as shown below.

The spike on August 4th around noon was due to some heavy outdoor work I was cutting down another storm blown tree. The following trend down into the red zone (again not dangerous) was a recovery period. To a degree this is repeated on August 5th at 6pm where I worked out hiking the Hardin Valley hill. During exercise my glucose climbed and then right afterwards it dipped again. That’s an interesting phenomenon that I’m going to have to study more. It happens more often with outdoor exercise than indoor exercise. Maybe the body heat, sweat, and evaporation have something to do with it. This is a good reminder that not all causes of glucose elevation are to be avoided or are harmful. As the body works it wants to fuel the cells and will send glucose out to do that.

My last meal of the day was at 5:30pm yesterday which was some roasted chicken, blueberries, and macadamia nuts. Then I started my 24 hour fast. I’ve tried to incorporate a 24 hour fast into my weekly routine starting Monday after dinner until Tuesday dinner. For various reasons this is the day I’m least likely to eat with my family so giving up a meal doesn’t usually impact our time together. As I write this I just finished up today’s only meal so the fast ended up lasting about 27 hours. I have to say I feel focused and calm more than normal and I have the ketones to prove it. I’ll tell you more about that tomorrow.

So after one week of ketogenic nutrition with daily net carb intake averaging 19.6 gms per day this morning’s ketone level was a solid 1.0 mmol/L. I hope that one week journey into nutritional ketosis show just how straightforward it can be and how it can be implemented in a very busy life.

Tomorrow I’ll share with you my ketone levels throughout a day of fasting. Stay tuned.

Nutritional Ketosis, Day 5

Saturday was day 5 of my journey journaling nutritional ketosis for my patients. It was a pretty busy day where I staffed Trinity’s walk-in clinic and then had lots of home chores to get to before school starts next week for the kids.

Breakfast was three eggs fried in ghee and a half dozen chicken sausages from Jones Farms that I’ve been meaning to try. I found these breakfast sausages at Costco a while ago and they looked like a pretty good option for a fast low carb breakfast. They tasted fair but not outstanding, too herby for me. So, they’ll probably stay on the grocery list for when I need something quick to get out the door but, despite the name, I won’t be jonesing for them. Breakfast yielded a net carb of 1.1gms.

During medical school and residency after a long night of call in the hospital, some of the best attendings would show up at morning rounds with a nice treat like bagels or donuts. In that tradition, I’m very appreciative of the team at Trinity and the exceptional fellow clinicians with whom I work that do most of the heavy lifting during our Saturday clinics. As such, I bring fruit, yogurt, and lower carb granola as a treat for everyone. While working I ate a Fage 2% plain yogurt and a 1/4 cup of blueberries. I’ve shown before that too many blueberries, which I love, can elevate my glucose so I had to resist the temptation to eat all of them. This time around there wasn’t much of a bump in my readings. The net carbs for the yogurt and berries was about 9 gms. Again, that’s if the carbs in plain, unsweetened yogurt need to be fully counted. The process of making yogurt uses up some of the sugars in milk.

I didn’t finish up work until mid afternoon so didn’t get to eat lunch until after 3pm. My ketone levels were solid at 0.9 mmol/L though. Same as post overnight fasting. That’s a really good mid day number for me.

For lunch I finished off the brisket along with an avocado and 2 oz of macadamia nuts. Net carbs were 7 gms. After lunch I went to work out at VitalSigns with my daughter. Interestingly, after an hour of cardio and strength work, my ketones actually went down a little to 0.7 mmol/L.

Dinner was a ribeye. Seriously, just 8 ounces of a deliciously marinaded ribeye. Net carbs were under 1 gm. It was a very satisfying meal.

The day’s total net carbs were right at 20 gms with a robust amount of fat and protein too. My glucose readings for the day were static under 100 mg/dL the whole time. This day produced an overnight fasted ketone level of 0.7 mmol/L.Tomorrow, when I write the entry about today’s journey (how timey-wimey), I’ll share with you what caused my glucose to bump over 100mg/dL and why I’m not worried about it.

Nutritional Ketosis Day 4

Friday August 2nd was the fourth day of my journey documenting how to achieve nutritional ketosis. So far my dietary intake of net carbs have been 10 gms, 17.6 gms, and 22.5 gms. Yesterday, I had 17.2 gms of net carbs. I’m averaging 16.8 gms of net carbs per day. Not bad, I think.

Breakfast was three eggs, bacon, sausage and cheese with black coffee. Lunch was beef brisket, an avocado, and a tomato with a spoonful of Purely Pecans sea salt pecan butter with unsweet tea. This stuff is very good and is often what I eat with apple slices. At 1.5 net carbs per tablespoon and 12 gms of fat it’s a great low sugar, whole food snack. Breakfast was 5 gms of net carbs and lunch was only 7 gms of net carbs.

I also need to give a shout out to one of my awesome patients who brought me some of the best tomatoes I’ve ever tasted. He came in this week for a routine follow up and we celebrated a reduction of his fasting blood sugar back to normal and a reduction of his fasting insulin by over 50%! Truly unbelievably good work. I’m so proud of you and happy birthday today!

Dinner was a naked hamburger patty topped with cheddar cheese, sauteed mushrooms, diced tomatoes on a bed of baby spinach leaves. Adding another spoonful of pecan butter made the total meal only 5 net carbs.

Again, my glucose readings remained pretty flat all day. This produced a ketone reading of 0.9 mmol/L this morning after fasting overnight. (I forgot to snap a picture of it before leaving the house this morning, whoops).

I’m pleased with this progress. I’ve been able to eat well and feel satisfied while producing a mild nutritional ketosis. My energy level is good and sleep is too. Both are things that I find deepen in their quality when I eat really well.

You may have noticed the dip in my blood glucose around 4-5 am noted in red on the graph above. I don’t have a definitive explanation of that. It could be associated to changes to cortisol and growth hormone levels that usually happen around that time each morning.

I remember that night as being a particularly dream filled night too. While we sleep our metabolic rate isn’t very much lower than when we are awake and REM sleep, where dreams happen, produces brainwave activity similar to doing those same actions while being awake. The brain consumes a large amount of the body’s energy needs at around 16% so it’s possible that my particularly intense dream consumed more glucose than a typical night. It’s also possible that my night time mental activity had nothing to do with my glucose as REM sleep is always dream filled, we just don’t usually remember it as such. Regardless, the dip, I believe, is inconsequential to my overall progress and health. The CGMs don’t measure lows as well as they measure highs and I always take numbers less than 60 gm/dL with a grain of salt.

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/