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:  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.


Karen said…
Wow Ev! Why dont you tell us how you really feel? :))
I read this blog because I have always gotten alot out of it even if I have not a clue what the scientific reports say. I trust what is said in recap and other's here take on it. This, I must say, is the first post (rant LOL) I have read that really makes me want to give up not eating carbs. I am diabetic tho and have to be careful. But I am convinced I need carbs.
A word about Rebecca, she is a friend of mine and has struggled so hard to lose the weight she feels she needs to. Tho I dont agree with doing the NK thing I hope the best for her.
Craig said…
Perhaps I'm a little slow on the uptake, but I'm not clear if there is any difference between the 'nutritional ketosis' that is discussed here and the 'ordinary ketosis' that nondiabetic LC fans have always tried to achieve. By going to extreme levels of fat with little protein and no fat, do you actually achieve substantially higher blood ketone levels, and maintain those long term?
log said…
It just bums me out that people like Jimmy have so bought into this completely wrong theory of weight control. Jimmy will lose weight doing this experiment because the diet is so incredibly strict that he won't be able avoid unintentionally lowering his calorie intake. Of course, he'll take the wrong lesson from this, and when the eventual regain happens he'll blame it on somehow getting knocked out of ketosis rather than on increasing his calories. In the meantime, fans of his blog are going to waste tons of money on keto testing strips.
Sanjeev said…
research on the Inuit & Yupik show that they produce few ketones probably because they take fatty acids all the way to water & CO2 without letting ketones escape the process. I absolutely don't buy the theory that enough glucose is made from protein to power all their activity, thus blocking the ketotic state.

At the same time the keto diet stays effective for epileptic kids for a long time; I've read 5 years bandied about, and ketones I think have been fingered as the effective compound in the treatment, therefore enough ketones to treat the condition are made and transported into the brain, even after 5 years.

So I don't know ... hard to say exactly what's going on. Definitely the amount of ketone that's urinated goes way down after a while; Of the long term reports I've read that mention tracking of urinary excretion, IIRC all reported that little tidbit.
steve said…
Your analysis seems to be overwhelmingly oriented towards weight issues in your discussion of low carb diets. What about the impact of carbs on cardiovascular health? The work of Dr. Ron Krauss who is by no means a low carb advocate shows that when carbs are reduced in the diet to a level of 100Grams per day or lower, LDL Particles not only decrease in amount, but they become larger. LDL-P and HDL-P are becoming more significant factors as biomarkers of cardiovascular health and carb intake affects these levels with mileage varying depending upon one's own underlying biochemistry/metabolism as to how restrictive you need to be.
Sanjeev said…
>> when carbs are reduced in the diet to a level of 100Grams per day or lower, LDL Particles

copy & paste to your URL text box:

or click here
Unknown said…
"Fat burning beast" ... careful that's a trademarked Primal term of art
Sanjeev said…
There are a lot of debunking posts and comments BUT

no one here has claimed low carb is all bad all the tine and no one should ever do it.

If our personal histories were different we might be on "30 bananas a day sucks"
P2ZR said…
I *was* wondering lately why Sisson hasn't subtly walked back from the fat-burning beast shtick, as he has with the uber-fattening carbs meme. That was until I by chance saw his 'updates' post on primal 'success stories'. There were maybe five of them, but keep in mind that these stories have been put out for >=2 years now, every week. (Self-selection, folks!)

Anyway, it struck me (being not so bright--it should have been obvious) that he CAN'T walk back from the fat-burning beast (hell yeah, Grok = 'beast'!) notion, and needs to keep working it--*especially* if he's going to tone down the carb police thing--because SO MANY of the MDA 'success stories' are people who lost weight (let's be honest, the major draw of primal(R)(TM) isn't the clearing of inflammation and whatnot, it's the weight loss)...did so via LC. Often explicitly crediting Sisson for introducing them to Taubes. Unless tons of people start writing in with stories of tremendous weight loss on tuber-/rice-based starchy diets, don't expect things to change anytime soon.
P2ZR said…
LOL but bananas have CALORIEZ! I'm betting that for most of us here, one commonality among our personal histories is that at one point, we all believed that calories are SOOOOO not created equal (if non-carb calories even count at all).

And honestly, bananas just aren't that palatable after a while. That's why the chubby vegans roll them in agave syrup and roll them around in crumbled raw nuts.
Gys de Jongh said…
A while ago I found this intruiging article. It discusses a theorethical posibility to make glucose from fatty acids themselves. No fat or glycerol needed.

If you live long enough on a very low carb diet you might have upregulated the enzyme systems for it like the Inuit and have no ketones in your blood.

PLoS Comput Biol. 2011 Jul;7(7):e1002116. Epub 2011 Jul 21.
In silico evidence for gluconeogenesis from fatty acids in humans.
PMID: 21814506
Unknown said…

Summarizing our findings, it can be concluded that a thorough, systematic and detailed in-silico investigation of the stoichiometrically feasible routes from fatty acids to glucose based on an experimentally corroborated genome-scale metabolic network provides new insight into human metabolism under glucose limitation. It confirms earlier, anecdotal evidence and hypotheses about gluconeogenesis from fatty acids via acetone and provides hitherto unrecognized pathways for that conversion. This provides a plausible explanation for the surprising independence from nutritional carbohydrates over certain periods (e.g. upon the low-carbohydrate diet of inuit, in hibernating animals and embryos of egg-laying animals).
bentleyj74 said…
Or blend them into smoothies with lots of added cocoa and coconut oil :)
Anonymous said…
Okay. against my better judgement, I am going to do this anyway!!?! I like you, let me say that up front! I have been reading your blog for over a year, and I am still waiting...I "Get it", BUT, what's the point? You are NOT better, No one is better, thanks to your take down of the so called "gurus"! So, again, WHAT is the point? I am a RN (like Woo), and have been for over 2 decades. We live in the thick of it! It IS insulin and fat tissue, and possibly other variables, BUT, WHY do you keep "defuncting" others, and never have an answer for yourself!?! I am sorry for being the person who finally asks "WHY"....

I am not
CarbSane said…
I think what most people consider a ketogenic diet, probably isn't in the long term. But it is possible where necessary for therapeutic reasons -- it is my understanding some epileptic kids have to have their foods measured out to the gram. It is a metabolic state the body resists at all costs ... but can be beneficial.

This NK is a true "ketogenic" diet. What's the point for weight loss? I don't see that as reason for this extreme. Not by a long shot. As in if I were in the business I'd never in a zillion years advocate this for weight loss.

Epileptics do not stay on the diet indefinitely, indeed most stay on the strictest form for a year or so ... some less than that.

Jimmy and wife had UTI's recently. Jimmy's came with a pesky fever and Christine's with a kidney stone. Nah ... just keep doing whatchyer doing.
CarbSane said…
I'm done with this sort of commenting. If you don't like me (which you do not despite the disclaimer), don't read. But please don't make a fool of RN's everywhere -- whom I have great respect for but also am well aware of their education -- by claiming your work as a nurse puts you in the thick of it and it IS insulin and fat tissue. You made a joke of yourself on your first comment.
Anonymous said…
Computer modeling is not new - and not for this task.

Figueiredo replied,

Interesting discussion.
Anonymous said…
'Never have an answer for yourself..'

Is that you, Mom?
ItsTheWooo said…
Your argument that low carb dieters are not in ketosis is wrong and easily countered by pointing out that children fed ketogenic diets for epilepsy will remain seizure free indefinitely on the diet. If ketone levels magically disappeared after 10-12 weeks they would be rockin and rollin with their grand mal attacks.

Also, if I pee on a ketosis stick and it turns pink or purple, where are those ketones coming from? My blood passes through my kidneys which filters wastes ending up in my pee pee. The ketones in my pee came from my blood. My kidney did not spontaneously confabulate some ketones to throw up on that stick. It came from my blood stream, which got them from breaking down lots of fats, which came from eating lots of mixed nuts and cheese.

I agree testing blood ketosis is a stupid gimmick; if a ketosis urinalysis is positive, so will a blood ketosis test. This will only fail to be true if one is taking drugs that can mimic ketones, such as valproic acid. The valproic acid molecule is synthesized from valerian, and looks like a ketone, and so exerts similar effects in brain/body (such as, altering GABA/glutamate and changing sodium concentration of cells to help epilepsy... and also, inhibiting glucose oxidation and adapting the body to a thrifty state as if in genuine ketosis, cuasing metabolic disorders if one is mainlining HEAPS OF CARBS while one is also taking valproic acid.)

There are other drugs that can fool a ketosis test as well.

The blood ketosis testing is BIG SCAM, because urine ketones are LESS sensitive than blood ketones. If your urine ketones are positive, and you aren't taking any medications, then rest assured your blood ketones are elevated.

The utility of blood ketone testing is to rule out a false negative ketone urine test to help type 1 diabetics who are sensitive to ketoacidosis. There is no way for ketone tests of the urine to be positive, but blood to be negative, unless it is a FALSE positive induced by medications.

This is why some diabetics might want to test blood ketones, but no chubby dieter would benefit from this (unless, of course, testing blood ketones encourages the dieter to rigidly restrict their food, which leads to weight loss in a round about way).
ItsTheWooo said…
Maybe Atkins wasn't right about everything. Shocking, I know. Maybe when Atkins told people they could eat anything they want and pee out extra calories, he was wrong. Last time I checked, Robert Atkins, MD was a cardiologist in new york, not a god. He was a chubby libra who figured out that old wives tales where eating less starches allowed you to lose weight helped him do that. So he wrote a book and pimped a diet, and ended up helping a lot of people.

Eating disorders are serious mental illnesses. Low carb eating disorders don't exist, but low carb obsessive fad dieters do.

"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. "

I did atkins when I was just 20 years old and I NEVER believed this. There was a time I ate a ton of rice, and I didn't freak out or feel like my life was over. I figured I would just continue the diet and carry on. At no point did I think that rice would KILL ME FOR LIFE.

Diets don't cause extremist mentalities. That's like blaming beer for alcoholism. If your brain is naturally extreme and polarizing, yea, you might have a problem picking up subtleties and understanding the gray areas even when assessing diet rules.

I remember being in my early 20s, young and dumb and new to this "dieting" thing, going online for "support" and being surrounded by tons of women in their 30s and 40s and 50s who were batshit crazy. Quickly I became aware that there was a certain type of individual who diets as if it were a social hobby; she really isn't trying to lose weight, it's more like a habit or an addiction. A professional dieter. She has been dieting since teenager years and it's like her religion.
I found this bizarre. Most of these women were trivially overweight, or they were slightly chubby but unremarkable for their age. The things they believed and would do to lose weight, quickly hit and was promptly laughed out of the room by my BS radar. Even at like 21 I figured out these women were utter idiots and lunatics and never at all wanted to join their crazy fads and gimmicks. That pesky habit of thinking/reasoning prevented me from doing this.

Anyway this group of loons is driven to crazy extreme eating behavior, so blaming low carb for their follies is like blaming budweiser for an alcholic bender.

I find it funny that Attia describes his previous body as very out of shape. He is very muscular and slightly overweight. No belly at all. His body type looks quite healthy with no signs of insulin resistance or endocrine disorder. Cry me a river! There are actual fatasses w. endocrine / metabolic disorder reading his site looking for help; it's almost insulting that he whines in this fashion.

That would be like me taking a picture of my new size zero jeans I just bought from being slightly tighter than the ones I bought last year and whining about it to a group of people who were trying to just be normal sized. OH NOES, I AM IN SERIOUS HEALTH TROUBLE NOW. I hath gone from a tight 00 to a tight 0. FUCK MY LIFE!

Attia's diet is pretty much identical to mine. I don't drink coconut milk and I am too lazy + cheap to cook steak, but otherwise it is the same entirely. Replace the steak with a chicken, and the other steak with some more nuts, and TEH SAME.

PS, growth retardation in children on epileptic diets relates to extreme protein restriction, a largely unnecessary qualification of the theraputic ketogenic diet for most epileptic patients.
Awesome. Please send this to FrankG and the other Taubes lackeys.
CarbSane said…
Wooo, Many kids treated with a keto diet are on it for only a year or two. Some longer term, but I've yet to read where any of these kids stay on it forever. Not saying that doesn't exist, just it's not the norm. Obviously running the brain on ketones for a while "heals" something or their seizures would return. Per below, about growth retardation, that is my point. The protein restriction is required to achieve high levels of ketones although use of MCT's seems to help. So now the new ketogenic diet is all the rage and folks will restrict protein and lose some weight. Good luck with the preservation of lean mass there.

When they measure blood ketones (see the two studies from the review, many other diet comparisons), they do taper off in the long haul.
Mike said…
"(unless, of course, testing blood ketones encourages the dieter to rigidly restrict their food, which leads to weight loss in a round about way)"

I have a growing suspicion that this is how all (successful) diet plans work...
CarbSane said…
BTW, regarding "better". I'm healthy, normal sized (but overweight), active, strong, and happy. I looked into this to make sure the diet was healthy in maintenance, particularly if one is carrying some extra weight. My conclusion is that it is not ... not in the way it is militantly promoted by failed low carbers. Would I like to be "better" -- yes. But, as I've said (if you do indeed read this blog) is that I know what I have to do to get to a lower weight, and it's a quality of life balance for me. I hope that makes sense. Meanwhile I've added back carbs to my diet and they certainly have improved how I feel day-to-day, in addition to sleeping much, MUCH, better these days.

Meanwhile, there have been many people who are better off weight and healthwise having learned that the LC dogma is a bunch of lies. If you've been reading my blog for a year, you've seen them post here, and I receive many more thanks via email.

LC is a good way for the very obese and/or insulin resistant to lose some weight. It is not a magic panacea, and there's just not ANY human culture we can look to that actually eats/ate this way. Not even the Inuit. So then you look at the promoters of this diet for whom it is obviously not working, and then you look at billions of living humans who are healthy and lean eating more carbs than the SAD. For betting on long term health, which diet seems the better one to bet your health on?

The Inuit may have given more meat v. fat to their dogs, but they ate high protein diets which is why they are not in ketosis and can pass an OGTT with flying colors.
CarbSane said…
Wheat Belly is proud of the success of the glucophobe diet. Measure blood glucose and convince the person they'll die if it goes much over 110 and that's powerful impetus to stay VLC.

Until you eat around the meter because a stick of butter doesn't impact blood glucose much.
CarbSane said…
You miss the point. If the internet was around in the 1970's all these people would be talking about testing urine ketones because that was THE way Atkins told people his diet worked. Many people still believe that and will make the claim. Now they're told to test blood ketones and that there is something superior to "nutritional ketosis" for health, weight and physical performance. Surely it will heal what ails all of these damaged metabolisms.
CarbSane said…
Interesting discussion of this by Chris Masterjohn:

My take on the in silico stuff is that it only says it's possible, but this really tells us nothing. Chris and I disagree somewhat on what would constitute a substantial pathway. Our bodies don't sequester and trap acetone very well -- hence the keto-breath -- for one.

But in light of looking at these diets, it would be fair to say that this is probably a small to non-existent source of glucose in "wild humans" eating whole foods. The fat comes packaged with too many carbs or protein in nature.
Sue said…
Bloody hell - what will they think of next.
Yeah, skip the nuts and cocoa and coconut oil and then you can eat all the bananas you want! Your brain (or sheer physical stomach fullness) will then naturally lead you to stop.

I say it's time to throw away all the diet philosophies and really learn to LISTEN to our bodies again. There's another very simple paleo aspect that is getting lost among the kettlebells and cold plunges.
Anonymous said…
'children fed ketogenic diets for epilepsy will remain seizure free indefinitely on the diet.'

There are several studies that follow kids fed ketogenic diets. Some do remain seizure free but 'indefinitely' is a real stretch. You'd have to follow those cases (a minority, in the studies I've read) for life, and that hasn't happened.

If seizure free, it is not linked to the diet; I'm guessing that's because it's not reproducible and such cases are not the majority. What is reported is improvement, a reasonable (and cheaper, I'd say) alternative to medication. When medications improve, they may be better, but because parents make the decision, kids may still use the diet because it's cheaper. If they can stand it.

Even with success, many just drop the diet. But ONE guy proved the rule by being the exception. He was on the ketogenic diet for 21 years, a model patient, and he did have growth problems.

Researchers note that the people who are recruited or volunteer have physical illnesses or conditions that confound. Slow growth is consistently mentioned. Not the only side effect, btw, but one that researchers watch with children.
Unknown said…
It's a great marketing gimmick because it draws the men in with the "beast" aspect. What fat guy doesn't want to be a beast? So you ditch the carbs and not only do you get to lose all that fat but also you can beat the crap out the guy who kicked sand in your face. Heck I might go for it myself I always wanted to be capable of ripping a phone book in half with my bare hands. I am fat burning beast, hear me roar!
TJ said…
The Razwell virus cannot be delivered via typing text into a blog entry. Your statement that Razwell is your reason for moderation to be turned on makes your readers think that you do knot know how computer virus are transmitted, or you are being dishonest as to why moderation is turned on.
Sanjeev said…
au contraire mon ami

she know't whereof she speaketh
Sue said…
I am reader and don't think that. Enlighten us why you think moderation is on?
Sanjeev said…
If you have a book to sell and in the run-up you've PROMISED the answer then, well then you probably feel you MUST pretend you have the answer

BUT ...

If the honest answer is "I don't know", what do you expect ... are you ASKING to be lied to, and INDIGNANT that someone won't lie to you?
steve said…
suggest you look at this:
and from Dr. Ron Krauss on diabetes and me:

hear you saying that the liver never starts out making teeny tiny pieces of LDL. It either makes one that has a lot of triglycerides in it, or more cholesterol in it.

Yes. We’re designed to be very flexible in how we handle our metabolism. In a way this has to do with nutritional conditions. Sometimes there’s extra fat around and sometimes there’s not. The liver responds to these different dietary circumstance by making what the body needs.

And sometimes there’s extra carbohydrate around.

Carbohydrate is much more of a factor than many people realize. People think that blood cholesterol comes from dietary cholesterol. That’s definitely not true. Dietary cholesterol coming in eggs and shellfish has modest effects on cholesterol. It’s much more effected by the type of fat and carbohydrate. The fat that causes LDL to go up is saturated fat. Animal fat. We’ve shown that it tends to affect the larger LDL, interestingly. What we tend to think of as bad fat primarily affects the less bad form of LDL, whereas carbohydrates, in a somewhat counterintuitive way, it’s starches and sugars that raise the bad form of LDL.

It sounds almost as though the body goes, oh, my goodness. There’s so much carbohydrate coming in. That’s a volatile fuel. Let’s make it into a bunch of triglycerides and go put it somewhere.

If the body gets more starch, it will use it to stimulate the storage of more fat.

I was a bit surprised to hear you say that All LDL is bad. It’s my understanding that we need some degree of this stuff to give energy to our cells and maintain them.
And this from Dr. Krauss
You may choose to listen to an exercise guy, where for weight carbs do not matter, but I think Dr. Krauss would differ with you regarding carbs and heart health regarding any particular individual. An NMR test is helpful in determining what carb level works best for any person. In my case( and i am not diabetic, nor overweight) carb restriction is best for my LDL-P profile.
Anonymous said…

Razwell seems to be a belligerent fellow. Spells better than his foes, though. So I'm guessing that Razwell = ranting post. Not an actual computer virus.
Sandy Daigler said…
The other thing that ketosis does is blunt hunger. So if you're on a very restrictive diet, you can stay on it more easily because you're not hungry. The weight loss diet I used last go around was low carb enough to induce ketosis and I loved it -- how else could I have stuck to 1200 calories a day? I'm not completely up on the science of ketosis, but my doctor says ketosis is not a healthy state to be in long term. I know doctors don't know everything, but at some point I have to trust someone on this.
Galina L. said…
As a person who uses ketogenic diet for therapeutic reasons for several years, I can tell that it is not necessary to be in a very deep ketosis in order to achieve results, it is also not an ultimate weight-loss tool, even though it almost eliminates appetite. I also found ketosis beneficial for avoiding hot flashes and mood fluctuations (I am 51 yo). It is possible to do it wrong, and being over-enthusiastic is the wrong state for doing things right. My body so far signals me that I am on the right truck, my husband came from visiting Moscow in June with a very nasty cold, had to take antibiotic, I sort-of felt like I was catching it from him, but after couple of days with slightly sore throat on the morning it went away. When I feel like I am getting sick or migraine is coming, I always do fasts or at least go into deep ketosis.

Jemmy Moore and his wife visited Tom Naughton and his family during 4-th of July week, and Tom posted about JM's ketosis experience. I left couple comments on Tom's blog about watching FBS while experimenting with ketogenic diet. BTW, the anty-epilepsy ketogenic diet was very hard crappy kind, difficult to tolerate and much harder to adhere than something like Atkins induction phase.I disagree with the ketoacidosis danger for non-diabetic person who limits carbs. You have to be a diabetic with no insulin for that to happen, the thing to watch for extreme LCarber is very pronounced physiological IR, which is reversible anyway.
On Tom's blog JM's wife Kristine left a comment that JM regained weight as a result of over-eating meat. If Jimmy needs to check overeating with very expensive keto-sticks, so be it. All better that balooning.
Mike said…
It's certainly more appealing than "Emaciated Meat-Avoider" or "Sugar Swilling Sissy".
Sue said…
Doesnt have to be low carb to stick to 1200 daily. It does help with hunger but it may not be enough long-term to remain compliant.
CarbSane said…
LOL ... so you're the one who Googled "Razwell virus"

Yes, as Sue commented. Please do enlighten us. It will help if you can refrain from bashing other bloggers and posting in all caps ;)
Galina L. said…
My migraines are caused by some wrong electrical activity in my brain which is epilepsy-like , I took an anty-seizure medication for about one year because of it. There is a big difference how medicine affects such condition and the effect of ketogenic diet. The positive effect of medicine keeps wearing out with the use, and negative side-effects get more noticeable. The effect of the diet feels like normalization, I don't think it gets weaker, my health improved, I have also less allergies and infections now. When we compare ketogenic diet with medicine for epileptics, lets not forget how poisonous the medicine is.I have a lady friend whose doter can't think about getting pregnant because she is on an anty-seizure medication, it is incompatible with pregnancy, damages liver, nails and hair get worse.
Anonymous said…
It's great that your particular epilepsy-like condition was improved with diet instead of medication. The Ketogenic diet has been used for various conditions since the 1920s. Some people do both - take medication and use the ketogenic diet. A decision for patient and doctor.
Sid Farkus said…
I've been reading that Diabetes Update website by Jenny Ruhl. She has a whole page on how your body and brain runs well on ketones ( That really raised a red flag for me, as studies have shown that mental performance deteriorates in the ketotic state. I stopped reading her site because of how dogmatic and alarmist she is. She makes dubious claims with minimal like T2 diabetics lose 80% of their beta cell mass before diagnosis (that's more typical for newly diagnosed T1 diabetics).

She also claims that the reason gastric bypass surgery reverses diabetes is because carb intake is lower. She totally ignores weight loss, increased insulin sensitivity and improved post-meal insulin production (incretin effect).

I don't know why CarbSane doesn't criticize her claims more, since many diabetics online treat her as some grand authority on the disease.
ShottleBop said…
Jenny got that 80% figure from Dr. Ralph DeFronzo, winner of the ADA's 2008 Banting Award:

"Dr. DeFronzo is the recipient of this year's Banting Medal, ADA's highest award for scientific achievement. In his award lecture, he said that at the time of diagnosis, most type 2 patients have already lost 80% of their pancreatic beta cells, and would benefit from newer classes of drugs that have been shown to reduce beta cell loss, the thiazolidenediones (TZDs) such as Actos or Avandia, and drugs that affect gut hormones, such as exenatide (Byetta)."

(Source: If you look up the full text of DeFronzo's article, "From the Triumvirate to the Ominous Octet: A New Paradigm for the Treatment of Type 2 Diabetes Mellitus" (available on PubMed:, you will read, in the first paragraph:

"Insulin resistance in muscle and liver and β-cell failure represent the core pathophysiologic defects in type 2 diabetes. It now is recognized that the β-cell failure occurs much earlier and is more severe than previously thought. Subjects in the upper tertile of impaired glucose tolerance (IGT) are maximally/near-maximally insulin resistant and have lost over 80% of their β-cell function."

My recollection of the study(ies) finding impaired mental performance during the ketotic state was that they were no more than a few weeks long, coinciding to a large extent with the period required for the brain to adapt to using ketones as a major fuel.

Jenny's take on gastric bypass surgery is colored by the fact that its results show up right after surgery, before any appreciable weight loss has occurred, so that weight loss cannot be the cause of the effect; by the risk of adverse effects from the surgery; by the (much more radical than any low-carb diet) many restrictions that patients have to live with following the surgery; and by the fact that many folks manage to restretch their stomachs and thereby lose whatever beneficial effects had been derived simply from having a smaller stomach. I don't recall seeing her reaction to reports/speculation that bypassing the first portion of the smaller intestine has effects on the body's hormone-signalling system that ameliorate symptoms of diabetes.

Jenny may have entered into the online discussion arena through the low-carb entrance, but she has been a vocal proponent of the proposition that there is no one-size-fits-all solution to dietary issues--she started participating in online discussions back in the user group days, and has interacted with thousands of people trying to lose weight, or control their diabetes, by dietary means. (Her newly-published book about low-carb diets addresses this in detail, acknowledging studies (and personal histories) that illustrate its issues and complications.) She reads the studies that she reports on. She doesn't dismiss accounts by individuals who report that their results did not comport with what might have been expected, based on this or that study--she recognizes that studies, by and large, report on group results and averages, rather than individual results, and thus tend to mask the fact that different people appear to have vastly different results from the same treatment.
CarbSane said…
Welcome Sid! I've been critical of Jenny from time to time here -- especially for her knee-jerk reaction to the crash diet reversal of diabetes. Most of the time she's pretty practical vis a vis the extent to which LC is useful and the limitations.

But you are right, she looks at T2 from her T1.5ish MODY eyes and bashes scientists and the medical profession for not properly treating T2 based on the very real fact that those treatments aren't appropriate for her condition. Most with her condition (and related types) are misdiagnosed and it must be frustrating ... doesn't mean she's fair in slamming the medical profession for their prescriptions for 80% of T2's.

Yes, for most they did eat their way to diabetes (albeit it might not be fair that someone else who ate the same way didn't end up diabetic) and yes, losing weight can help, and no, VLCal diets are not dangerous starvation schemes under properly supervised conditions.

The way I see it, the effectiveness of crash diets, GBP, and/or early insulin therapy present a problem for those who want to *manage* T2 when in many cases it can be reversed. I do my part trying to spread the word that even w/o early diagnosis it may still be possible to eat "normally" and be diabetes free. At least it is worth a shot.

I do believe the myth that one's beta cells are hopeless by the time of diagnosis is dangerous, wrong and needs to be set straight. I'll try and speak out more on this. :D
rodeo said…
Defronzo is fishy. He is tied to Amylin who makes Byetta and has started a cancer scare about a long acting insulin. He would profit equally from having people believing in a beta-cell scare.
CarbSane said…
Yes, ketosis is appetite suppressing in some, more than others. This effect seems highly individual in both magnitude and duration.
Sid Farkus said…
Based on that link about DeFronzo, he recommended the use of Actos and Avandia in early diabetes. At the time of that article (2008), both drugs were considered risky; now Avandia is not available in the US and Actos is being banned in other countries. GlaxoSmithKline had to pay a huge fine ($3 billion) partly because of Avandia's side effects.

How come Jenny Ruhl deliberately misinterpreted the Newcastle weight loss study? Nobody had their stomach stapled in that, and 3 months later (while eating normal diets and gaining back a few kgs), 7 of 11 went from diabetes to pre-diabetes. The subjects were still overweight and had peripheral IR, yet they had a major improvement in insulin secretion. It seems that the loss of visceral fat in the liver and pancrease may have been the reason for the improvement.

Doctors usually use the fasting C-peptide to determine residual beta cell mass (that's how they distinguish T1 from T2). There does seem to be some beta cell loss for T2 in the beginning, but not the 80% that DeFronzo claims.
Sid Farkus said…
Also, you say that Jenny says there is no one-size-fits-all approach to diet. Why does she say that all diabetics must keep their carb intake to well under 100g, or they're going to have skyrocketing blood sugar and are going to die? I don't support veganism, but there was some book which said that eating such a diet can reduce/eliminate the need for medication while eating mostly carbs (the improvement is mostly likely due to calorie restriction and associated weight loss). She peddles lots of alarmist nonsense, and she doesn't seem to have a problem associating with a fraud like Jimmy Moore. I guess scaring the hell out of people is a way to sell your books.
CarbSane said…
Just a little while ago I was thinking the TZD's might make good early therapeutic agents b/c they target glyceroneogenesis and reduce fatty acid levels. Unfortunately these agents have bad side effects, no doubt due to the reciprocal regulation in different tissues that unfortunately can't be mimicked (yet?) by a targeted oral compound. I'm personally more up on Byetta as it is an analog of a peptide we produce ... thus may have dose related side effects (nausea when injected prior to meal vs. secreted in physiological amounts in response to food normally) and there is some evidence to support it increasing beta cell mass or at least protecting against losses.

If DeFronzo made the claim, he's no better than anyone else and he would have to back up that claim. I've read a lot of his work. If he's for earlier intervention, I'm in agreement, though I definitely think early insulin treatment is the way to go with some pretty impressive clinical evidence to back that up. If I were diabetic I'd do it if the crash diet didn't work ... what do I have to lose? Progress to insulin dependence anyway, or perhaps reverse my diabetes? Hmmmm....

That figure apparently comes from the SAM and VAGES studies discussed here. The upper tertile of IGT -- that's top third of those with IGT -- beta cell FUNCTION had declined. It seems clear that beta cell function in the acute phase can be reversibly impaired. This is not what Ruhl says, or how it's interpreted. From the shownotes of her JM podcast ( "How people first diagnosed with Type 2 diabetes have lost 80% of their beta cells" I took this on here: (you might want to skip my rant on Jimmy's diss)

For someone who is highly critical of science and medicine, she does play a bit fast and loose with her version.
CarbSane said…
Oops ... forgot the link to SAM and VAGES studies discussed here:
Sanjeev said…
> You may choose to listen to an exercise guy,

if you're going to try to poison the well you could be more subtle about it.

So what's my choice, an "exercise guy" whose head seems screwed on fairly OK, and whose analysis usually looks balanced and skeptical,


a seeming internet monomaniac

CarbSane said…
@Sid, I'm glad to see someone else sees some of Jenny's statements as alarmist. I was beginning to think I was imagining things sometimes.

One alarmist thing that can be traced to Jenny is this notion that glycation sets in at 140 mg/dl -- which is more than alarmist as it equates any instantaneous or transient reading to what occurs if your basal glucose essentially never falls below that. I guess I don't focus as much on her as she's not presenting and being interviewed all that much. I haven't listened to her Diet 101 on Jimmy's yet (if ever?)
Galina L. said…
Some people, especially not young ones with hepatic insulin resistance may notice their fasting blood sugar getting higher after long period in a deep ketosis. It is not a pathology but an adaptation of your body, it gets reversed when you slightly increase the amount of consumed carbs. My GP knows I follow a ketogenic diet since 2007, he has no problem with it,several of his patients do it with beneficial results and no one had a problem so far, but he commented he couldn't recommend it because it is not the standard of care. I think, I would monitor my FBS if I were you in order to be sure it is at reasonable range.
Sid Farkus said…
There's no question that beta cell function is compromised in T2s, but is mass compromised, in the beginning at least? Basal C-peptide is elevated in most T2s, yet that's what doctors use to diagnose T1 (death of beta cells leads to massive reduction in basal C-peptide).

I don't know if you heard about those Canadian researchers (at the University of British Columbia) who reversed T1 diabetes in mice using human embryonic stem cells. I don't think think this is a long term solution for human diabetes because of the foreign DNA being rejected and the ethical issues, but they need to find a way to convert adult stem cells to the same state as embryonic cells. They also need to resolve the autoimmune issues for T1 diabetics.

Incidentally, there have been studies on T1 diabetics, replacing part of their immune system with stem cells, which led to a major increase in insulin production, to the point that many could get off of insulin for a period of time (not forever, I think the autoimmune issues were still present to a certain degree). Also, there have been studies overseas on T2 diabetics who were injected with their own stem cells from bone marrow, causing a major decline in blood glucose. The way I see it, the cure/reversal of diabetes, whether it is T1 or T2, will likely involve stem cells to regenerate the beta cells.

I think for T2 diabetes, it is imperative to lose weight (it doesn't have to be crash dieting). That's the biggest problem that most T2s can't lose enough weight to have a dent in their disease. Gastric bypass is the easiest solution for that, but one should try to lose on their own at first.
bentleyj74 said…
"Diets don't cause extremist mentalities."

Lots of things can create extremist mentalities/behaviors especially when they tread on behavioral/conditioning psych. You don't have to go digging around very deep or cast your nets very wide to find all the studies that had to be abandoned halfway through 'cause the ordinary healthy usually college student population was exhibiting psychotic or sociopath behavior.

Stanford prison experiment is an easy example but certainly not unique.
ShottleBop said…
@ Sid: "Also, you say that Jenny says there is no one-size-fits-all approach to diet. Why does she say that all diabetics must keep their carb intake to well under 100g, or they're going to have skyrocketing blood sugar and are going to die?"

Link, please. I'd like to see exactly what she said, and in what context. Thanks.
Sandy Daigler said…
Galina, I'm not eating a ketonic diet anymore. I did it for about 6 months to kickstart the weight loss process.
Sid Farkus said…

"Myth Busting: Your Brain and That "Required" 130 Grams of Carbohydrate
My email has been filed this past week with emails from people with diabetes whose doctors or nutritionists have told them that it is dangerous to eat less than 130 grams of carbohydrates a day.

It isn't true. In fact, for most people with diabetes the opposite is true: eating more than 130 grams of carbs a day guarantees blood sugars that are so high they raise your risk of blindness, amputation, kidney failure and heart attack. "

Right there, plainly on her website; she says that if you have diabetes and eat more than 130 grams of carbs a day, whether on medication/insulin or not, your blood sugar will skyrocket dangerously out of control and you will develop severe complications.
CarbSane said…
Wowzers! That's pretty strong hyperbole there.
Galina L. said…
I don't think everybody should be in ketosis, the initial period of a strict carb limitation is enough for some to brake the cycle of excess hunger or put body in a right track. For example, for Dr.Emily Dean it is enough to just avoid grains and refine sugars in order to be healthy. However, I would not avoid some diet that works for me just for the reason that somebody scared me in a medical office or on some web-site.
Josh said…
this is another goody - "tragically, the way that today's doctors are forced to diagnose diabetes ensures that you will get no warning that you are experiencing those chronically high blood sugars until they have done their irreversible damage. This is not an accident. Years ago a committee of medical experts whose task was to decide how diabetes should be diagnosed decided it was better to avoid diagnosing patients with diabetes than to give them early warning that they were suffering pre-diabetic elevated blood sugars. As a result, these medical experts intentionally set the standards for diagnosing diabetes artificially high, so that most patients will not get diagnosed until their blood sugar reaches a level where they are in serious danger of going blind." (Misdiagnosis By Design - The Story Behind the ADA Diagnostic Criteria - BloodSugar101)
ShottleBop said…
@Sid: So, to your way of thinking, saying that Jenny has written that ". . . all diabetics must keep their carb intake to well under 100g, or they're going to have skyrocketing blood sugar and are going to die is an accurate report of a blog post in which she wrote: "for most people with diabetes . . . eating more than 130 grams a day guarantees blood sugars that are so high they raise your risk of blindness, amputation, kidney failure and heart attack"?

Duly noted.
LeonRover said…
"Wowzers! That's pretty strong hyperbole there."

It is good to see you agreeing with ShuttleBop that SidFarkus is as hyperbolic as equation "X*Y=C".

CarbSane said…
Oh lord. To be honest, I haven't read much of her website. She seems quite moderate when she comments about the net and in her interview with Jimmy (haven't listened to latest podcasts). But this is the sort of over-the-top hyperbole that discredits a person.

Her form of diabetes is very rare. Despite the inflated statistics -- including the undiagnosed -- diabetes is still somewhat rare, just over 8%. So her form is like 2% of that. She seems angry -- rightly so, perhaps, she sounds quite level headed so I'm willing to give her the BOD that her anger is justified -- at being misdiagnosed. But she extrapolates her experience to the whole profession and treatment of all diabetes. I think that's unfair.

Dr Parker in his podcast with Jimmy basically apologized for the horrendous way the medical profession has treated diabetics. In the next breath he went on to discuss how decades ago diabetics died young, now they live into their 70's (I don't recall exact numbers so this is paraphrasing from memory). Well, hello! The medical profession MUST be doing SOMETHING right by diabetics.

If anything this prediabetes is the scam. Get more labeled and hooked on glucose testing supplies. That is a racket!
CarbSane said…
I would agree that Sid upped the ante in his representation of what Jenny wrote. But what Jenny wrote remains strong hyperbole ... he just made it a bit stronger.
LeonRover said…
"he just made it a bit stronger."

Yes, stronger to the point of misrepresentation.

Are you in favour of misrepresentation?

ShottleBop said…
When you're accusing someone else of playing fast and loose with the facts, isn't it better to be as accurate as possible yourself, rather than indulging in hyperbole? A "bit" stronger? There are huge differences in meaning between "all" and "most", and between "raise your risk" and "going to die." (After all, one of the things you're making a ruckus about is Jenny's reference to an 80% loss of beta cells, vs. an 80% loss [b]of beta cell function[/b]--and during a podcast interview, at that.
ShottleBop said…
"If anything this prediabetes is the scam."

Wow. Talk about "the sort of over-the-top hyperbole that discredits a person"! Did you even read the report on the SAM study you linked to? SAM was all about prediabetes. It found that, by the time the 2-hour OGTT results of a person considered to have normal glucose tolerance reached 120-139, he/she had suffered a decline of some 60% in beta cell function. SAM found a loss of 80% of beta cell function in people recognized as having impaired glucose tolerance--but not considered "diabetic": those whose 2-hour OGTT results fell in the 180-199 range.

Speaking as someone whose grandfather lost his sight (and ultimately his life) due to complications from diabetes, whose uncle lost a leg to diabetes, and whose mother--and many aunts and uncles (and now cousins)--lived/have lived with diabetes for several years, I'm very thankful that my "prediabetes" was picked up at an annual physical some 4 1/2 years ago. That piece of knowledge--and my use of a meter to help determine the effect that different foods have on my blood sugar levels--have, so far, helped me to avoid further (visible) progression. Yeah, the cost of strips is high--the meter/strip market is often (fairly, I think) compared to the printer/ink market--but for me, and for many others, spending the money on the strips now is truly a stitch in time.
CarbSane said…
Please, step back a bit and realize this is a comment, not a blog post or website page. You are being very critical of Sid for his wording but not of Jenny for her own. And now me for mine ... which is fair, but since this is my home, I get the prerogative of asking you to know a little bit about me before you pounce. You're talking OGTT's and the truth of the matter is -- and this is even confirmed anecdotally and worse -- prediabetes used to be established by 2 FBG's of 110 or more (1998) and now it's (2003) 100. In addition to inflating stats with the *IMPOSSIBLE TO KNOW* undiagnosed, many times they include this pre-diabetes. NEVERMIND that only small percents EVER convert to diabetes. The prediabetics number over 3X DIAGNOSED diabetics.

So, yeah, I think when you look at that threshhold of 100 mg/dL being well within the range of LOWEST all cause mortality in a large prospective study on middle aged men for 23 years? Eh ...

Are you saying an OGTT should be routine screening?
ShottleBop said…
@Evelyn: Sid came here specifically to ask why you seemed to be giving Jenny a pass, then proceeded to wildly mischaracterize what she had actually posted about carb ingestion and risk of complications. Under the circumstances, I think it fair to require that he at least accurately report the advice that he is criticizing. Were Jenny actually saying that every diabetic who didn't keep his/her carb consumption to under 100 (or even 130) grams a day would develop complications and die, I wouldn't have said anything.

OK, so Jenny said that "most" diabetics who ingest 130 grams of carbs a day would raise their BGs high and "increase their risk" of complications. Yes, she might better have added something along the lines of "at least, those who don't keep their blood sugar to safe levels by some other means". Yes, I might have said "many", rather than "most." I might even have limited the comment to Type 2s (although Dr. Bernstein would not approve of such a limitation :D). But I'm not Jenny. (As it happens, however, Jenny herself, in the comments to that blog post, clarified why she had posted what she did: "The answer to your question [as to why she recommends limiting carbs, and relying on gluconeogenesis from protein to pick up the slack] is that some people with Type 2 diabetes do not have access to excellent medical care or have doctors who refuse to prescribe insulin, so they can't tolerate more than a very small amount of carbohydrate without going high. I do better with a slightly higher carb intake myself, but I can only eat that way when I inject insulin, because I will spike with more than 10 grams eaten at once. For years I could not find a doctor who would prescribe me insulin because my fasting blood sugar was near normal. So I had no choice but to eat a very low carb diet.") In context, I see little reason to label Jenny's advice as unduly alarmist.

Similarly, Josh reports above, without more, a statement by Jenny regarding the original provenance of the ADA's diagnostic criteria that is, I believe, intentionally provocative. On her website, however, Jenny follows that statement with several more paragraphs that explain her assertion in some detail. Again--in context--I find her to have provided substantial support for her characterization, even though I myself might not have stated the conclusion in such strong language as does she.

[To be continued . . .]
ShottleBop said…

Regarding prediabetes: if your real beef is with the change in diagnostic criteria for prediabetes from an FBG of 110 to an FBG of 100, you're right--that was a huge increase in the population suddenly diagnosed as "prediabetic" (according to the "Counterpoint" editorial I link to below, from 7-10% of the world's adult population to 30-40%). Interesting arguments, pro and con the change, were published in "Diabetes Care" for May 2006 (at ("Point"), and ("Counterpoint")). The "con" editorial, for example, points out that, while 6-, 7-, and 8-year studies from three different countries had found the percentages of folks with FBGs in the range 100-110 (5.6-6.0) who developed diabetes during the study period to be low (1.8% in one study, 2% in another, and 14% in a third), those studies had also found that much higher percentages of folks with FBGs over 110 (6.1-1.9) went on to develop the disease during the study period: from 43% to 55%. The "pro" editorial, on the other hand, asserts that the 100 mg/dl (5.6 mmol/l) criterion "came closest to providing 100% sensitivity and 100% specificity for future diabetes", and noted that "[d]ata from >450 intravenous glucose tolerance tests show that first-phase insulin secretion begins to fall once the FPG rises above 90-97 mg/dl (5.0-5.4 mmol/l)."

Personally, while I think someone with an FBG of 100 or more should be apprised of the fact, should educate him/herself about diabetes (maybe pick up Gretchen Becker's book about the subject) and should engage in enough monitoring to determine whether his/her postprandial BGs are (or become) unduly high (and that an OGTT might even be administered at that point, to determine whether there is cause for immediate concern), I don't know that a full-court testing press is necessary at that stage. On the other hand, I do think that anyone with an FBG of 110 or more should be taking affirmative steps to reduce his/her risk of developing full-blown diabetes.

In my own case, the distinction between 100 and 110 as a diagnostic threshold is moot: I was diagnosed as "prediabetic" some 4 1/2 years ago, based on two successive FBGs of 127 and 123.* By that time, my A1c was 6.5, high enough to have gotten me diagnosed as diabetic, had it happened a year and a half later; and I consider myself functionally a T2.

* Recently, I discovered a copy of one of my old physicals from 1978: my FBG then was 101. And in 1990 or 1991, I passed an OGTT. So, no, an FBG of 100 is not quite the wakeup call that an FBG of 110 should be.
ShottleBop said…
I'd throw regular A1cs into that mix, as well, and keep in mind the research correlating A1c to cardiovascular risk . . .
ItsTheWooo said…
Living to 70... in the nursing home, with amputations, and kidney failure, and/or a rotten useless brain. <---That's what 70 looks like when you have diabetes.

Diabetics died young because in the past many more diabetes were type 1 (as we did not yet invent cheap corn sugar to turn every maternal liver and fetal brain metabolically damaged at birth)
If you had type 1 you were dying quickly, end story.

Now days most diabetics are type 2 and that is a long slow death of lots of complications. You don't just die in a few weeks like with type 1. We have many more diabetics than we did in past generations, and that increase comes from the type 2 form with acts like a slow degenerative disease.
OnePointFive said…
'Living to 70... in the nursing home, with amputations, and kidney failure, and/or a rotten useless brain. <---That's what 70 looks like when you have diabetes@

Well I've only got 10 years to go then, still managed to run the London marathon last year though so my decline will have to be quite rapid. I have no intention of losing a limb or ending up with kidney failure.
Some of these T2s from Team T2 have even fewer years before their dotage.somehow I think they will avoid it.
Aren't they better role models than the Jimmy Moores of this world?
I doubt many of them spend their time trying to get into nutritional ketosis.
CarbSane said…
Wooo, I realize you're working in a nursing home jades your view, but as OPF points out, you're painting a very negative picture. More likely these people went undiagnosed because they weren't in the "preventative medicine" system which isn't always an access issue, but lack of desire to participate.

The lifespan and quality of life for diabetics has improved vastly with the advent of insulin pens, differing duration of action, insulin pumps, etc. as well as other drugs like Byetta which may not work for everyone, but is also no more a drug than synthroid.

Hey congrats on the marathon OnePointFive!! That's awesome.
bentleyj74 said…
It is true that diabetics in nursing homes have a pretty shoddy quality of life but the fact that they are *in* a nursing home means they are a better example of things like the broken elder care system and medicare/medicaid fraud than they are either a representative of the gen pop or a cross section of diabetics in general. I have personally known people with diabetes who lived to their late eighties independent and without any serious health complications such as amputations. They were compliant with their treatment and they could afford good treatment. It matters.
ItsTheWooo said…
@Evelyn - I've been in many hospitals as part of my training. Same deal. All the beds are filled with diabetics.

Diabetics getting CABGs
Diabetics being treated with IV antibiotics for pneumonia/osteomyelitis/cellulitis/random other infection.
Diabetics with ESRD and an exacerbation of CHF.
Diabetics with an ungodly eye-watering brutal non-healing wound that is being treated by the wound care physician, debrided, or amputating a limb.

The nursing home is an extension of the hospital these days, Evelyn. Where do you think the CABG patient goes when their 5 days of insurance runs out? TEH NURSING HOME!
Where do you think that 65 year old diabetic with a wound vac and IV antibiotics for 6 months due to osteomyelitis is going? TEH NURSING HOME!

Hospitals are in and out procedures, unless you are super critical. Then you go to the nursing home for rehabilitation therapy, and post surgical care. Or, unless you are super healthy and recover in 2 seconds, but then if that's true, YOU AREN'T TEH DIABETES.

Gotta laugh at all these people making snide remarks about "the education of nurses" and "working in a nursing home" when you have no idea how american healthcare even operates.

I assure you the 70 year old diabetics are not enjoying their golden years in good health.
ItsTheWooo said…
Yesterday I admitted this patient:
~60 year old obese female with type 2 diabetes. Left leg above the knee amputation all the way up to the hip. The right leg has an ulcer that we have been trying to heal for the past few months (read: she lost her legs to diabetes)

Today I admitted this patient:
~75 year old very thin lady with type 2 diabetes. Just developed gastric cancer and required a gastrectomy and cholecystectomy (read: she got cancer from contributing hyperglycemia and immune system dysfunction). She has a history of CAD and multiple cardiac stents (read: her heart is fucked from diabetes). The very involved family informed nursing they noticed a sudden decline in her alertness and energy level. Her temp on admission was ~100, according to the records her previous temps were ~97. (Read: she is probably developing an infectious process from her surgery because of, you guessed it, HER DIABETES).

Living those golden years in styyyyyle! But what do I know, I'm a retard idiot nurse in a nursing home lolz.
ItsTheWooo said…
As your moniker states, you are a 1.5 diabetic. YOu are nothing like a type 2 diabetic and cannot relate to their concerns. You are much more in common with a type 1 metabolically healthy subject. Just as you don't seem to understand why type 2s need to restrict carbs and can't just inject insulin like you or a type 1 or a MODY diabetic, you are also not likely to succumb to the complications because exogenous insulin will manage your condition entirely, assuming you are compliant with blood sugar checks and insulin coverate and monitoring/observing how your blood glucose responds to variables.

This is not the case for a type 2 diabetic who is intrinsically DISEASED in the liver, and in the very core of their cells. Whereas your c-peptide is barely detectable, theirs will be extremely HIGH. They are rarely insulin deficient, and often hyperinsulinemic in the early phases. The problem with type 2 diabetes is that the cells are like that of a corpse - they are half dead - they simply fail to generate energy normally. No matter what this person does, they will succumb to illnesses UNLESS THEY STOP TRYING TO USE GLUCOSE FOR ENERGY. THe best therapy for the type 2 is getting off glucose ASAP, using non-insulin dependent sources of nutrition like fats, and maximizing glucose tolerance as much as possible via micronutrients, weight training/moderate exercise, good sleep patterns and so on.

Here's a little chart to illustrate the differences in insulin secretion and resistance between 1, 1.5, and 2. As you can see, 1.5 is pretty much type 1 that occurs in old age, with some insulin resistance but not significant.

The fact you laugh at type 2 diabetics on low carb diets, would be like someone with situational laughing at a manic depressive for taking lithium. Situational depression may resolve without life long medication, but bipolar disorder will NOT. Sure, both of these people have a condition considered by doctors to be described as "depression" but the etiology and treatment of the condition is radically different. The various categories of diabetes are just like this. You have no idea what type 2 diabetics experience and what treatment they benefit from, because the news flash is for yuo: it isn't the same as type 1, type 1.5, or mody diabetes.
CarbSane said…
Wanna dial it back a bit please Wooo? You know all there is about T2 because you're an RN in a nursing home, OPF doesn't know squat as a T1.5? C'mon!

FWIW, My mom spent a few weeks in a rehab (knee replacement) facility housed in a nursing home. Her room was in a separate area, but residents were not segregated. The place was also a maze so I frequently got lost when going to visit her. I saw a lot of depressing situations, but everyone had their limbs. Not saying there might not have been a diabetic who lost their limbs, but your penchant for exaggeration seems to be at play here.

Also, a lot of the complications you are talking about are associated with T1 diabetes as well.
CarbSane said…
@ShottleBop: Sorry, I had a response yesterday but I guess I forgot to hit the Publish button :(

I'd like to back this bus up a wee bit here and point out that I said "if anything". Sorry, I don't believe the medical profession deliberately misdiagnoses or waits until diabetes is already progressed ... so "if anything" it seems like they're trying to diagnose more people with a condition with "diabetes" in it.

A huge part of the problem is that hyperglycemia can have various causes. Of T2's, 80% are obese and their obesity "caused" the diabetes. It may be true that some may have become diabetic anyway far later in life, but the chronic caloric excess that produced the excessive fat mass tripped the trigger.
I've been meaning to address this page on Jenny's site:
A toxic myth? Please!

I think Sid somewhat mischaracterized Jenny's statements, but I wouldn't call it a wildly so. Josh's was a direct quote, and reading it in context doesn't mute the alarmism

What's really strange to me is that prediabetic FBG's seem to be quite common in low carbers. I know it's not necessarily a representative sample, but when long term low carbers are getting diagnosed prediabetic (as Jimmy Moore would now be depending on which days he was tested, for example) that cannot be due to their diets because they don't eat carbs. And many will justify their elevated BG's as "normal" physiological IR and such.

Jenny called a diet that reversed diabetes idiotic and harmful. I'm no fan of GBP but one cannot just scoff off the rapid reversals of diabetes even before significant weight loss by pointing to the risks of the surgery. There's a lesson there ... that beta cells are far more resilient than folks like Jenny have led people to believe.
ProudDaddy said…
Let's not forget that the 600 kcal diet that produced similar results to GBP was for only 8 weeks. It had enough fat to prevent gallstones and did enormous good. How is that harmful?

While I think the incretin as reason for GBP success argument is solid, the VLCal aspect may also be at work.

Do we know that all T2Ds aren't pumping out enough insulin? Wooo could be correct in the sense that a significant number of, not all, T2Ds have a liver problem. One thing in the VLCal study that tracked immediately with improved glucose control was hepatic and pancreatic TG content.
CarbSane said…
I think the sudden, enormous calorie deficit is what sets it all in motion in both. It's hard to ignore an incretin effect, but even in VLCal it could well be that the incretin production rebounds quickly ... but maybe a little quicker with the bypass. If the T2's in that crash diet study or undergo GBP have a liver problem, it too resolves quickly. I just find the high percents where glucose metabolism is normalized (even if it didn't last, which suprisingly it does to varying degrees) indicate whatever is going on is not irreversible damage. Not that it doesn't happen -- to varying degrees and progression rates -- but that it is not irreversible damage.
CarbSane said…
IMPORTANT: Left off last part of that last sentence. Not irreversible damage in "classic" T2 diabetes, and it would seem for far longer down the pike than previously thought.

In this regard, he may be corrupted by interests, but DeFronzo is right that aggressive intervention early is the key.
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Cristina said…
I was forced into treatment with an idiotic dr who told me I had insulin resistance and prescribed a military like regime of everlasting fase 1 south beach diet. A year later I was dying with the results of being a disciplined patient who had believed in a licenced M.D.

You are right to warn people about the dangers of very low carb diets, not enough people know how dangerous they can be.
Myron Schwarzennecker said…
What specific health problems did you have?
Ross said…
You got sick NOT due to low carbs, dear. All that "medication" you took, ever think that played a role in your condition? As for low carb, to do it CORRECTLY, it's low carb, MODERATE protein, and high fat. YOU should've done your research as well. Point you took "medication" for being obese, without having your pancreas checked, and you blame low carbs is plain idiocy.
MacSmiley said…
Is Attia board certified anywhere? Or does anyone who completes a residency able to claim the M.D. sheepskin? It's obvious from his own admission that he's never been a practicing clinician.
carbsane said…
He has never practiced after that. You only need the degree to keep that MD after your name. Many functional medicine docs like the one who will educate us all on the role of candida in diabetes do not hold board certifications.
MacSmiley said…
I find it hard to believe that a doctor who quit medicine to go into the financial sector could possibly have my best interests at heart.
carbsane said…
I'm not even sure he has his own best interests. He seems to be another one of those self-experimenters ... but in a recent video he has some telling responses in the Q&A in the end. He does this more to push the limits and see how his body responds (almost sounds like see how much it can take) ... and he basically likes the buzz from ketosis.

Meanwhile he achieved 90-95% of his improvements before going ketogenic.
MacSmiley said…
BUZZ? As in intoxicated?
carbsane said…

If you listen from about the 1:08 or 1:08:30 mark here, he talks about why he does this and how it has not been a benefit in all aspects. Pretty interesting.
MacSmiley said…
Good point about the pre-ketosis 90-95% improvement.

As for the buzz, or acute focus, I've heard the same thing anecdotally about therapeutic fasting. Evidently, when a body is starving, finding food requires some massive mental focus. Makes sense of the religious experiences some have experienced via fasting.

I can't imagine that simulating "survival mode" for such an extended period of time can be healthy.

With the millions of $$ he and Taubes are getting by way of NuSI, I'd love to see a few intravenous ultrasounds if their arteries. Seth Roberts should be a cautionary tale for them.
MacSmiley said…
Watched. Replied above.
Ancestral Chemist said…
This is exactly what happened to me, except self-inflicted. I was 15, size 2, convinced that VLC was the answer to life, the universe, and everything. I ate ~30g net carbs/day for a little less than 3 months, so there was no time for the sympoms to progress beyond crushing fatigue and dry skin. I don't want to think about what would have happened if I hadn't found the Jaminets' website... I know they play loose with facts like other paleos, but they really have saved some people from their own demented paranoia.
carbsane said…
I will always give the Jaminets credit for being a lone voice in favor of consuming carbohydrate. If only they didn't take it so far :(
Gordon said…
Evelyn, I have a copy of The Art & Science of Low Carbohydrate Performance and I'll send it to you if you're still looking for one. NK did not agree with me. When friends started asking my wife if I had cancer, the experiment abruptly ended. Very abruptly. Good thing, too. I can handle LC, but VLC was a disaster ...

If you don't mind my asking. What was it exactly about your appearance and general health that got your friends to wonder if you had cancer?

Gordon said…
My weight dropped from the mid-160s down to 150 over a 4 or 5 month period(I'm a 6'0" medium-boned 54YO male). My body fat dropped from around 10% to half of that. I had veins prominent on my abs while standing relaxed. My cheekbones stuck out, with hollows underneath. My clothing hung on me. I was getting a lot of calories, too. Over a one month period in the middle of the slide, I added a weekly half gallon of heavy whipping cream to my already high calorie diet in an attempt to stem the loss. That's an extra 900 calories per day. It made no difference. This would make some people very happy and they'd call the diet a success. It scared the crap out of me.
Sadly, it helped one of my friends confirm his bias and he's still ketogenic. A ketogenic evangelist, even. He weighs about the same as before, but his body composition is worse, IMO. I'd call him skinny-fat with an extra 20. It's been years, too. I worry about his liver. I've had to give up trying to talk sense into him, as he's on the verge of not being a friend any more. Very sad.
carbsane said…
Hi Gordon! Thanks for the offer but I have both books. I'm sorry to hear of your experience. I am pretty horrified at some dietitians even adopting this regime. To me, any such extreme diets should be approached from a cost-benefit therapeutic angle. For weight loss and diabetes there are better ways than this n=1 nonsense eating a diet wholly unsuited to human physiology. I believe only neurological and perhaps some cancer (not keen on that from what I've read though, seems overhyped) applications warrant limited use of this diet.
Yes. I could totally see a majority of people hopping on this as some kind of proof for MAD and even a positive aspect of the diet. Also confirmation bias issues would run rampant.

Sorry to hear about your friend. Doesn't always pan out the same for everyone.
Gordon said…
It gets worse. He has a wife and kids. He convinced his wife to try a KD. She gained weight and he(of course) accuses her of cheating. Now she's trying Medifast. He analyzed the ingredients and decided that it's OK because it's ketogenic, nevermind all the manufactured weird indigestible starches. One of his daughters doesn't like vegetables. He's convinced his wife that it's OK if she eats none. Zip. Nada. The more I learn about gut biome, the more dangerous this sounds. It's like watching a train wreck in slow motion.
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