Nutritional Idiotosis

There's a new wave sweeping through the low carb internet, dubbed "nutritional ketosis" by Drs. Stephen Phinney and Jeff Volek.   Apparently Volek actually lives this stuff, no idea about Phinney. (EDIT:  In this video, he says he's been nutritional idiototic ketotic for 7 years.)  These two teamed up with Dr. Eric Westman to write The New Atkins (TNA) before writing their own book The Art & Science of Low Carb Dieting and now The Art & Science of Low Carb Performance.   I read TNA, and gave it a rather favorable review, though I had concerns.  Have not read the A&S books, but as always if anyone wants to donate their copies to science I'm happy to have a look!  

It is interesting that V&P (how they signed that Pope petition makes me wonder sometimes if there really are two people - grin) and Volek in particular, are so enthralled with ketosis as the goal for low carbing.  In TNA, it was really nowhere to be seen other than using epileptic diets as an example of the acceptability and therapeutic use of the diet.  I blogged about this here.  But anyway, long story short, nutritional ketosis is all the rage these days.  I think it would be instructive for many to read the following review paper:

Low-carbohydrate nutrition and metabolism  Eric C Westman, Richard D Feinman, John C Mavropoulos, Mary C Vernon, Jeff S Volek, James A Wortman, William S Yancy, and Stephen D Phinney

A veritable who's who of the low carb nutritional world there.  NOT referenced in TNA.  That's right.  One of the things about TNA was that it specifically contained all that sciencey stuff you were supposed to be able to bring with you to the doctor's office when discussing your healthy low carb diet.    Except not this one.  Here's the important part to the topic of this post:  

Two longer-term studies, in persons without diabetes, that measured fasting blood -hydroxybutyrate concentrations over 10 wk found that, whereas the concentrations increased over the first 2–4 wk, they then decreased and, after 10–12 wk, remained only slightly higher than those of dieters following other diets (21, 23).

This is important because they measured blood ketones.  The longer term adaptation seems to be to "power down" the glucose burning as much as possible -- for which ketones can be largely but never entirely substituted -- and burn fatty acids.   Gluconeogenesis creates glucose from some amino acids and the glycerol backbone of triglycerides.   This source calls amino acids the main source and glycerol as a significant source of GNG precursors.  Many low carbers describe their diets as ketogenic when, indeed, they are only borderline so if at all.  

Atkins had everyone going to the diabetes supply section in the pharmacy to purchase ketostix to test for urinary ketones.   Perhaps if folks don't understand me and why I do what I do, they might "get it" when they realize that theories of how low carb works have been around a long time and when each is disproven, evermore intricate schemes have had to be spun.  But Atkins was the first to popularize his.   On pg. 94 (paperback version, Sept. 1973 printing, ©1972 Bantam), The Diet Revolution Calorie Theory is stated:

 Calories in equals calories used plus calories excreted unused.

In the original version, Atkins was a CICO man.  His "paradigm shift" was to roll back this notion that eating fat makes you fat, but he made a plain, easily understood, CICO based argument.  (He also spoke of a fat mobilizing substance in the urine but that was never identified, no it was in addition to ketones, not the ketones themselves.)   I have misplaced my copy at the moment so I can't give you page numbers, but just how many times Atkins bragged over patients eating thousands of calories in a day and still losing weight cannot be overstated.  Atkins may not have denied CICO, but he believed you peed out a boat load of unused calories as ketones, and thus he was also the source of this notion that you could be a fat and protein glutton and not get fat.  This is also how Atkins created low carb eating disorders in some who became obsessed over just how easy it was to "drop out of" this magical ketotic state.  Because it takes most people a couple of days to get into ketosis, it is a convincing argument that a bite of potatoes can set you back several days on your low carb diet.  I believed this when I did Atkins the first time.  

There's a problem with A-CICO, however.  The calculations have been done and the calories excreted in urine as ketones are nominal ... like 20 cal/day.  Yes, this can add up and over time sure, they up CO, but they are nowhere near accounting for the supposed ability to consume even more calories of fat and protein and losing weight.  But this A-CICO would provide an answer to that plateau so many seem to hit. Because when one becomes keto-adapted, most will find the pee strips no longer turn purple -- in other words, over the long term, you don't "spill" ketones anymore.  This makes sense as the enzymes for creating and utilizing these substrate are upregulated, etc., the body becomes more efficient at regulating both production and usage.  It is odd to me how many LC studies will still use urine ketones to assess compliance, such as this Westman study.  In any case, WV&P are aware that in the long term, ketosis is nominal on a usual low carb diet as measured by blood ketones.   Now many attribute this to carb creep, etc., but V&P have found the new bogey mancronutrient:  PROTEIN.

You see, sufficient dietary protein will prevent ketosis and can even keep your glycogen stores pretty full.  The horrors!  Your fat burning beast is burning fat and making all the glucose it needs to keep your blood sugars stable without pooping out your liver!    But no ... some are still obsessed with the magic of ketosis.  It's all I can think that would cause a former medical doctor who lost all the small amount of extra weight he needed to going regular low carb to self-experiment with this new holy grail of low carbing:  nutritional ketosis.  I'm talking about the former warrior against insulin but still Taubes boy wonder side kick, Peter Attia.  

Peter Attia has changed his website name but you can get directed there from the former url: waroninsulin.com.  Speaking to JumpstartMD -- a weight loss program that employs a low fat (lower than WW), low carb, CICO based approach -- Attia discusses how he eats like 400-500g fat per day close to 90%.  He discusses how resistant his body was to going into this NK nirvana -- the most resistant Phinney had ever seen!  This man burns through a lot of calories in a day because he works out around 3 hrs a day.  Yes you read that correctly. His regular diet and, it would appear, his initial LC diet is like 4000 cal/day and now in NK it's 5000 cal/day.  I'm using round numbers here folks, no time nor stomach to re-watch these vids.  

Now I can't figure out why this man, who despite medical training had like 20 pages of notes/questions for Gary Taubes on how our bodies work based on a work of science fiction journalism rather than going back to his textbooks, but that's besides the point.  If indeed his caloric intakes are as reported, what is there to "gain" here?  He now needs to eat more (expensive) calories to meet his needs because he's become Mighty Metabolism Mouse, and he puts out an appealing spread of foods he eats, but one has to realize just how much of each he's eating to get to NK.  When you consume that much fat, it's almost impossible not to consume a ton of that in dairy fat and to keep under 50g carb/day he's not getting too many from berries if that greek yogurt is a fat source.  If you look at the fat sources, if there's anything at all to concerns over omega 6's, Houston, we have a problem.  The beef and dairy may be low PUFA, but the ratio is unfavorable, and the veggie sources are high PUFA and an even worse -- that's right -- O6:O3 ratio.   When I come across them, I blog on FA contents of low carb foods, here's the label.  Currently avocado fat tops the list.  Not overly high in PUFA by % (14), but the O6:O3 ratio is 13:1.   Any way you look at it -- be it ratio, caloric percent in the diet, or absolute amount -- if there's anything to this, Attia is a trainwreck just waiting to happen, and the ketogenic mice with those screaming metabolisms?  Well, they don't fair well (and I would note that the SKD in the paper Mario linked to is hardly what we're talking about here!).

So a while ago, after tipping the scales at over 300 lbs, Jimmy Moore set out on his latest extreme dieting experiment.  Heck, maybe he can get a reality show on Lifetime or OWN or something for all of these ... it would beat being such a fraudulent hypocrit having his podcasts and websites sponsored/advertised on by all manner of products containing ingredients he claims he would never put in his body (and therefore wouldn't sell you to put in yours).   Folks, blood ketone meters are intended for diabetics so they can test and check for the prevention of deadly diabetic ketoacidosis.  The testing supplies are expensive - but what's $2-6 per strip when your health is supposedly on the line.  I agree.  If I were T1 diabetic, this is something I'd have in my arsenal.  But it's sheer idiocy to bother with this and worse than peeing on relatively affordable urine sticks unless you have a therapeutic IMPERATIVE to elevated ketones.  Period.  I really have become disillusioned lately with these people and their schemes.  Of course Jimmy is losing weight, because to maintain NK you have to eat pretty clean.  The last time he did so, he lost like 30 lbs in a month, this time 20.  Perhaps he's finally succeeded in breaking his amazing metabolism.  Oh and Tom Naughton is going to give it a try, because Jimmy was able to play 130+ rounds of frisbee golf without passing out.  Are these people for real?  Really?  I recognize Rebecca Latham of "I was in TNA" fame.  I take it she hasn't gotten her handle on maintenance just yet.  It's just all so absurd.

Let us go back to evolution, ancestry and all that and the Peter Attia not an MD anymore because I left medicine after residency (completed?).   Come on.  I think we can all agree that humans evolved, adapted and all that to consume a variety of whole plant and animal foods.  This nonsensical "nutritional ketosis" would be next to impossible to achieve by doing that ... which is why I call it nonsensical.  Such a diet should only be attempted if there is compelling reason -- e.g. epilepsy -- for doing so.   The anti-epileptic diets, mostly for children, are not without risks/downsides -- the most prominent of which are growth retardation and kidney stones.  ANY diet with such well-document risks needs to be carefully considered on a risk/benefit basis.    Don't walk around with such dogmatic blinders on that you can't consider whether a ketogenic diet is superior or inferior on a risk/benefit balance vs. drugs.  Especially when such a diet can in no way, shape, or form be described as a natural diet for homo sapiens.  I.T.  J.U.S.T.  C.A.N.T.

Let's put those P.C.S. hats on for a moment.   If your body resists something very strongly, would not the logical conclusion be that such a state is not desirable?  Think about that, please!  You starve your body of carbohydrate, it goes into conservation mode.  It has to make glucose and it makes ketones because that is the only quantifiably significant way to meet glucose needs (by substitution) from stored body fat.  But after a while, your body finds ways to make better uses out of dietary protein to avoid excessive ketone production ... at the expense of your muscle tissue if need be.  Why would that be?  If your body and cells actually "prefer" ketones, why does the human metabolism go to such great lengths to fight this in the near-to-long term?  Simple.  Ketosis is NOT a preferred metabolic state. You cut out an animal's pancreas or knockout all of their body's insulin receptors, and what happens.  Death. And what is the cause of that death?  Not hyperglycemia.  Not even lipotoxicity.  Ketoacidosis.  Repeat ... it's the ketoacidosis that kills.  Not the carbohydrates, not the glucose, not even the NEFA.  No, it's the unchecked formation of ketones that at too high a concentration are deadly.  Drop DEADLY.  Perhaps there's a reason human bodies reject this except on unnatural therapeutic diets.  But even if not deadly, otherwise mysterious renal system issues are explained.

So nowadays some people are fucking (yes I cursed, sometimes it's needed) with their metabolisms, trying to skirt on the edge of Type 1 diabetes.    Their bodies resist like crazy and their answer is to starve them of protein too.  It may be a short term solution ......... Nutritional idiotosis alright.