My Notes from The Diabetes Summit 2017
An Interview with Amy Berger MS, CNS
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Breaking down the Ketogenic Diet for Blood Sugar Control
A ketogenic diet is a diet that is very high in fat, you get most of your calories from fat. You get a moderate amount from protein and very little from carbohydrate. What that is designed to do is to force a shift in the way that the body uses fuel. People who are eating a high amount of carbohydrates generally run most of their body on carbohydrate. When you remove that amount of carbohydrate from the body it’s forced to fuel it with something else and it will turn to fat. It’s not a binary process, where we are either running on fat or carbohydrate, the body is very complex. We run on a lot of different things concurrently at the same time, but dominantly one fuel will be more prevalent than the others. The ketogenic diet is designed to make that primary fuel be fat, it’s such a fundamental biochemical shift in the body that it effects almost every tissue and organ system in the body. the number one thing that it does, specifically with regards to diabetes, is get you off the blood sugar roller coaster. Instead of having these wild ups and downs all day you have just these gentle little peaks and valleys like it’s supposed to be. Like it will go up and down but no where near as much as volatile, it’s not going to swing up and down as much as when you’re eating a lot of carbohydrate.
I do think ketogenic diets, or very low carb diets that are not necessarily medically ketogenic, are a very good way to control blood sugar. I don’t think they are the only way, there are other ways to do it that may be suitable for some people with certain preferences or certain genetic tendencies. I don’t think it’s right for everyone but certainly it’s right for a lot of people. Especially those who struggle to control their blood sugar or their weight on a more standard higher carb approach. The body does not need carbohydrate, the body needs glucose. It is not a lie to say the body needs glucose, it does. But the fact that we need glucose doesn’t mean we have to eat carbohydrate. For example, we need vitamin C, it doesn’t mean we have to drink orange juice, we can get vitamin C from a lot of different other foods.
The need for glucose does not apply a need for carbohydrate, even if it did we tend to confuse the word carbohydrate with starch. We think carbohydrate implies something like a grain, a starchy grain, bread, pasta, potatoes, rice, beets, parsnips, the starchier vegetables. People forget that lettuce is a carbohydrate, cucumbers and asparagus, broccoli are carbohydrates they’re just not a starchy one. Even if you are zero vegetables whether they’re starchy or not, no vegetable, no fruit, nothing but meat and fat, your body would make the glucose that your body needs. The liver does put glucose into the bloodstream like it’s supposed to, when the body is well regulated. It kind of trickles out slowly over time to keep your blood sugar even between meals, that’s what is supposed to happen in a healthy body. In a type 2 diabetic that process has become derailed and it doesn’t work. So it’s true that the liver does put glucose into the body but in the properly regulated healthy body it does so very slowly over the whole day.
By removing the vast majority of carbohydrates from the diet it’s almost impossible not to have improvement in your blood sugar. It may not get you all the way, there may be other tweaks you need to do like exercise, fasting or better sleep, something. But since dietary carbohydrate is the number one contributor to elevated blood sugar it makes sense to just remove it. First do no harm, first lets remove the thing that’s causing the most damage. Protein raises glucose a little bit but we need protein. I think there’s a lot of people that actually are under eating protein, they’re not eating enough of it. If the number one contributor to those high blood sugars is starch and sugar then get it out of the diet.
The difference between a ketogenic diet and a low carb diet is very important, some of it is a matter of semantics and some of it is more complicated than that. They are both low-carb, what they have in common is the reduction of carbohydrates. A ketogenic diet, at least in the sense of using it as a medical therapy is very, very high in fat. On a low-carb diet you might be able to eat 60-75 grams of carbohydrate a day, and that’s especially compared to the standard American diet that’s still significantly low. On a ketogenic diet you might be restricted to less than thirty grams a day, maybe 40, maybe even 20 for some people. And you’re making up a lot of the difference with fat. Some of this is used in neurological conditions, especially something like epilepsy where there is an excitability in the brain. The very, very high fat content really modulates that, it calms it down, it calms the brain and central nervous system. The major difference between those two diets, the low carb and strict ketogenic, is the ketogenic generally people are going to be aiming for a certain percentage of their calories come from fat. Whereas on a low-carb diet you’re eating a little bit more carbs, maybe a little less fat, and maybe a little more protein. Because of the effect of protein on blood glucose and insulin on a strict ketogenic diet, not only do you have to limit carbohydrate, but most people have to limit protein.
There are reasons to apply all different types of diets for different circumstances and personally I’m starting to see a lot of people doing a strict ketogenic diet without a good reason. There is a lot of people who are already fit, already healthy, thinking they have become alarmed based on what they see on social media. They have been scared into thinking that they have to eat eighty percent fat or they have to eat less than seventy or sixty grams of protein a day. For some people that’s madness. I think a very strict ketogenic diet is wonderfully therapeutic, I hate to use the word curative, but we can manage many, many medical conditions really beautifully with it. Unfortunately people have that mentality where, well, if that’s good then taking it even further is better. If eating less carb is good then eating no carb is better, or fasting for ten days is better. I just think we have gotten off the rails a little bit because both of these diets can work great in the right context.
I don’t want to scare anybody away from eating a ketogenic diet but I don’t want everybody to think they have to eat that way. The ketogenic diet, there is a lot of people especially type 2 diabetics, who have been diabetic for a very long time and are very far down the disease process that just going low-carb might not be enough for them. They really have to be very strict about it and something like carrots, or some type of vegetable that’s a little bit on the sweeter side that might be allowed on the low-carb diet, on a strict ketogenic diet that might be too much for somebody. There are definitely cases where the actual ketogenic diet is going to be best because people will just not see their blood sugar get better if they only go low-carb, some have to take it to the next level.
I don’t think most people have to measure their ketones. What measuring does more than anything in my opinion, is give people motivation. It’s encouragement, when you see proof that you’re in ketosis you’re like, yes, my body is working it’s doing what it’s supposed to do. But, we shouldn’t confuse being in ketosis with loosing weight or even with having low blood sugar. Because peoples body’s really vary in their ability to generate those higher ketones. Some people, especially those younger athletic people, mostly that are non-diabetic, can have blood glucose over one hundred and still see ketones of two or three. Maybe lower if they’re measuring blood ketones, most people will not really have that. If you are trying to have high ketones for a specific therapeutic purpose like Alzheimer’s disease, maybe even cancer treatment or some type of neurological thing. Then maybe you do want to measure because you need to see if what you’re eating and your lifestyle practices are getting you to the level that you need to be at for a therapeutic purpose. But for most people, most diabetics measuring blood sugar is probably going to be far more important than measuring the ketones. The important thing is to keep your blood sugar managed, to keep your insulin managed, to feel well, to have energy. Some people are going to do that at a very low level of ketones, some people will do that at a high level. When people are posting on social media, oh here is my ketone meter I am at 4.0, and someone is doing all the right things and working so hard and they never get above 1.0 or 1.5, they shouldn’t feel like they are doing something wrong. Measuring ketones is expensive so that’s another thing working against it. If you have money and you want to make yourself crazy do it but for most people who just want to improve their blood sugar I don’t think it’s important to measure.
There are products that have come out claiming to raise ketones, it’s a bit of a mind field having ketones in your blood from an outside source. If you drink a powder or take some kind of food product that has outside ketones, will raise your ketone levels. That does not mean you are in nutritional ketosis, it just means there are ketones in your blood or in your body. I think the vast majority of the benefits of a very low-carb ketogenic diet come not necessarily from the presence of the ketones, but it’s the absence of the glucose. It’s the absence of all the garbage that we put into our body. It seems to be the majority of the therapeutic benefits of ketosis come from the biochemical process that forces you to produce the ketones, not just by magically having the ketones there.
That being said, there are reasons to use these outside ketones, they’re called exogenous ketones, exogenous meaning from the outside. One of those could be for something like Alzheimer’s or some other issue where the ketones themselves do have an effect. They are not useless, but they are not a weight loss product. The thing with the exogenous ketones is they have a very short half-life, I think about an hour and a half. They are like a supplement, you take them so within three hours or so they’re gone. Compare that to if you are following a diet and having other lifestyle practices that keep you in a perpetual state of ketosis 24/7, even if it’s a very low level. That’s where you’re going to get your best bang for your buck not from these outside ketones. Some people do say they are helpful for making the transition so if you are currently following a standard American diet or a very high carb diet, if you use these products in the short term it eases the transition into ketosis. It might prevent some of the headaches, nausea, dizziness, some of the adverse effects that we get while our body is literally going through withdrawl from sugar. They should not be marketed as a weight loss tool or for providing all the benefits of a ketogenic diet.
Especially for blood sugar, insulin sensitivity and diabetes control, is the benefits come from cutting the carbs. And from the body producing the ketones by burning fat, not necessarily just having ketones in the body. Especially for someone who already has high blood sugar, we have a lot of fuel, so to speak, in the blood a lot of substrate in the blood. Now we’re going to dump all these ketones in it, the body isn’t prepared for that because normally, unless it’s an out of control type 1 diabetic in dangerous ketoacidosis. Outside of that circumstance, you’re not really supposed to have high glucose and high ketones at the same time and I don’t know what the effect of that would be. I don’t know why someone eating bagels and orange juice would want to take ketones. To me that just sounds like a recipe for disaster at the mitochondrial level, and at the cellular level, it’s just too much fuel.
It’s a lot easier than people realize but it does require some more time in the kitchen. Depending on your budget if you’re not made of money you are going to probably have to cook a lot more of your own food. The kinds of convenience foods we rely on to grab and go they’re not going to be low carb. If you are going to stick to this and make it easy for yourself you are going to have to spend more time in the kitchen. Probably more time at the grocery store reading labels. A typical day of eating, in the morning you could have “breakfast foods”, you could do eggs, bacon or sausages. You could have leftover chicken, leftover meatloaf, people just have to think creatively. Breakfast is just a time to nourish yourself it doesn’t have to be specific breakfast foods. Just because you’re no longer eating pancakes, waffles and bagels, doesn’t mean you have to replace them with eggs and sausage. You could have a three egg omelet with some low-carb vegetables, chopped up green pepper or spinach, onion. I make my own ketchup with no corn syrup, no sugar, but if you want to use some kind of condiment like hot sauce is good, mustard is good, anything with no sugar.
Lunch, the possibilities are endless, you could do a steak salad, you could grill a bunch of steaks on a Sunday so you have leftovers during the week. Cut it up into strips, put it on a big green salad with some cherry tomatoes, cucumber, radishes, celery. If you’re out with coworkers get a bunless burger, a pork chop and vegetables. Diner, a good size piece of protein whether it’s chicken or fish, bison, and a big pile of non-starchy vegetables. It’s pretty hard to overdo carbohydrate from broccoli, eggplant or zucchini, there is so much fiber. And really they are mostly water, there is very little digestible carbohydrate. I like to tell people make your plate one third animal protein and then fill the rest up with vegetables. If you’re on a strict ketogenic diet and you need very high fat content you can just add some extra fat. If you want to add some olive oil, melted butter, ghee, if you need to get to a specifically high fat content. It’s easy to eat this way but you do have to prepare in advance. On a Sunday don’t waste your time boiling one or two eggs for breakfast, boil two dozen eggs and leave them in the fridge. If you are baking or roasting a pack of chicken breasts bake two or three packages you can eat them cold as a snack, cut them up, dip them into guacamole or ranch dressing. This is not hard it’s just different, it’s very different from the way people are used to doing things but that doesn’t mean it’s difficult.
No one has to do a carb-up day, it’s not necessary. It can be helpful if somebody really thinks for some reason that eating delicious steaks, cheese and vegetables is a hardship. If they find this diet is a difficult thing that they get to eat fatty, if having a carb day or a carb meal once a month is what allows them to stay strict with the diet. The rest of the time it’s not the best thing, but I think that’s ok. Once a month, but that should be gauged to the individual depending on how far along the diseased process are they. Are they a diabetic, are they obese, are they suffering from depression or anxiety. If they have some sort of condition that that food is actually going to trigger, even just one meal, they have to decide whether that’s worth it or not. For most people it’s probably not. Athletes, people who are generally healthy and are active have a higher carbohydrate tolerance to begin with. They can probably tolerate that kind of excursion more than someone who is really metabolically damaged, and that might dictate how often they do it. I don’t encourage it, but if someone is going to do that I would recommend either fasting for a little bit beforehand and working out. In other words give that carbohydrate somewhere to go, if you could go into that meal or that day with that glycogen relatively low at least that carbohydrate has somewhere to go. Into your muscles, into your liver, it’s not automatically going to shoot your blood sugar up or be stored as fat.
There is what we call the low-carb flu or the keto-flu which is during the first couple of days when you make the transition from a high carb diet to a low carb diet. You are literally going through withdrawal from a drug, and that drug is sugar. Anyone who doesn’t think sugar is a drug should try giving it up cold turkey for a week if they have a six pack of soda a day habit. As your body is making this transition you no longer have the glucose you’re used to running on. Your body has not yet ramped up the biochemical processes that use the fats and ketones efficiently, so you’re kind of in this metabolic limbo. That’s when you get the headaches, and the nausea, dizziness, fatigue, but that’s normal. If you know that that’s normal and you know to expect it you don’t worry about it, and the worst of it passes in about two days. It’s going to take your body longer than that to really adjust to using fats and ketones efficiently, but the worst of the symptoms should be gone within a couple of days.
I think the challenges to sticking to this are preparing, you have to cook. You can do this without cooking if you want to spend a fortune at restaurants or hire a private chef, buy all prepared foods from a health food store. You do have to take the time, it doesn’t have to be a lot of time, you can do it once or twice a week, you could take two hours and knock our several days worth of meals. That’s part of it being responsible for making sure that you have suitable foods ready to go at all times. The other challenge is probably sabotage from friends and family, well meaning, oh just have a bite of this it’s so good you have to try it. Most people can say no thanks I’m good but, some people don’t want to rock the boat, grandma made these cookies for you, you can’t say no. You either have to be strong and stick to what you know is best for yourself or choose to eat whatever it is and accept the consequences. Maybe the consequences is elevated blood sugar for a couple of hours, maybe it’s a headache. Who knows but you have to take responsibility for the choice you make.
For some people self-sabotage comes from a number of reasons, for some people if they are specifically doing this diet for weight loss. Or maybe weight loss in conjunction with better blood sugar control or fewer headaches, less anxiety. Unfortunately, we tend to hang our hats on the weight and if somebody’s not loosing weight they say this is not working for me why bother. Maybe they’re not loosing weight but their fasting glucose has dropped thirty points and they’re on less insulin. Their skin has cleared up, they have all these great effects. But because they were so invested in loosing weight and maybe that didn’t happen quite yet they want to abandon the diets. I think that’s important too, is to have a lot of different metrics by which to measure, whether or not this diet is actually having some sort of benefit for you. Some of the low carb research shows that even in the absence of weight loss peoples blood lipids get better, the sugar gets better, the insulin goes down. Even if you don’t loose weight doesn’t mean nothing beneficial is happening on the inside.
It’s almost easier to say what doesn’t the ketogenic diet improve. It’s obviously very good for blood sugar control, very good for lowering insulin for insulin resistant people. Very good for weight loss, excellent for stabilizing energy within the physical body and the brain. People that have chronic fatigue, people that are just lethargic, you fundamentally change the way your whole body is fueled, all of a sudden you have all this energy. Why, because, you’re tapping into the fuel source your body stores the most of, even a relatively lean person still has a lot of body fat on them. When you could use that fuel instead of the little bits of glucose in your body, you all of a sudden have access to this huge amount of fuel to energize you. It’s very good for cognition and for the brain, one of the quickest things people report when they switch to this diet is that the brain fog goes away. It’s like someone has turned on the lights or cleared out the cobwebs. So much of what we call brain fog or fuzzy thinking is these dips in blood sugar, these wild ups and downs. When your brain is not receiving proper fuel of course you don’t think correctly, you can’t remember things.
This diet is also an anti-inflammatory diet so a lot of people with joint pain, stiffness, muscle pain, find that it clears up relatively quickly on this type of diet. Acne, there is so many things that we don’t realize are related to unidentified food intolerance’s, usually to a lot of foods that we cut out on a ketogenic diet whether it’s gluten or grains in general. If you have the money and you want to make your food a slightly higher quality, we get rid of things like soybean oil and safflower oil and some people react negatively to those high omega 6 oils. Hormone imbalances too, especially women with PCOS that’s strongly related to insulin resistance. Men with low testosterone because when you lower insulin levels it’s almost unbelievable how many things it effects when you normalize your metabolism. You are resetting your metabolism to the way it is supposed to be so it’s no wonder you feel great, you’re supposed to feel great. You’re not supposed to be in brain fog, pain and fatigued all the time. Your new normal becomes feeling great.
Ketones are extremely helpful for Alzheimer’s disease and mild cognitive impairment, sort of the precursor to Alzheimer’s. Alzheimer’s disease is now regularly referred to in the scientific literature as type 3 diabetes or diabetes of the brain. It is not up for debate that Alzheimer’s results from a loss of the ability of neurons in certain regions of the brain to metabolize glucose effectively. For people out there that are new to this the brain needs a lot of energy, it usually runs on glucose but it can also run on ketones. The reason it doesn’t work on ketones most of the time is because most of us are eating a high percentage of carbohydrate. When there isn’t a lot of glucose around and a lot of insulin around the brain will use glucose. When there is not enough to go around the brain has no choice but to use something else and that something else will be ketones. Ketones essentially serve as a fuel for these neurons that were previously starving. They have done studies where they have given people these exogenous ketones, they do have improvements in cognition, they have improvements in executive function. These ketones, at least in the research done so far, they don’t do anything to stop the disease progression. They can improve the symptoms in the short term, which is huge benefit and that shouldn’t be underestimated. But they don’t do anything to halt or delay the disease process. I think that the ketogenic diet can because, whether it’s because of the anti-inflammatory effect or the lower insulin.
Dr. Dale Bredesen has done some really amazing promising research with where he has reversed full blown diagnosed Alzheimer’s disease. Where they can actually see it on the brain scans that the brain tissue has actually grown back. Part of what happens in Alzheimer’s disease that you could see is the brain atrophy’s, it actually shrinks. He has done studies putting people on, he doesn’t call it a ketogenic diet, he calls it a lipid based metabolism. I don’t think his program is strictly ketogenic, he did MCT oil supplementation, coconut oil, fasting, lots of sleep, stress reduction, exercise. It’s a multipronged intervention, but they actually reversed diagnosed Alzheimer’s. People who had to give up working because they were so far gone they had to quit their job, these people are now back at work. I think it’s been a couple of years in some cases since they followed up, so we don’t know what the long term prognosis is for some of these people. Considering that there is literally nothing else to help people with Alzheimer’s why don’t we try this diet that we know for a fact ketones will fuel these neurons, they will provide an energy substrate to these starving brain cells. Why not start there and then see what happens over the long term. There are zero effective pharmaceutical drugs for this condition, there are things that help maybe in the very short term or very, very slight symptom reduction. but in effect there are zero effective treatments for this condition and I don’t know why a ketogenic diet and use exogenous ketones together isn’t the first line of therapy. This should be standard of care and I think it will be someday, I just hope it doesn’t take another thirty years.
Her book is The Alzheimer’s Antidote.
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