Yeah, I've Got That: ketogenic diet

Edited to correct HDL reference range and add footnotes found in my blood work results - apparently someone was too impatient to get out and mountain bike and forgot to check their work :)

So, in my last post I mentioned the 'helpful' email I received from my insurance company *rolls eyes*; they are so 'helpful' that they are now requiring you to meet their health standards score to save money on your insurance premiums. You are scored based on your blood pressure, LDL cholesterol, glucose, triglycerides and tobacco use status; if you do not meet a minimum target score, or improve your score next year, your premiums go up. My indignation over this Big Brother approach and whether it is reasonable, is fodder for another time; I thought some might be interested my blood work as a real life long term paleo/low-carber (sorry, I've only got the last two years on hand). . .

For context - my diet has been 'paleo' for over seven years now, low carb-ish without carb counting; I've entered my diet into FitDay randomly over the years to see where all the values were falling out, but my diet is pretty consistent, so I don't track day-to-day. Last fall (again, for context after my 2014 blood work) I made some minor changes in my diet to shift into nutritional ketosis, confirmed via urine test strips - or, as I saw in a comment the other day, measuring my peetones - heh! Slightly less protein and slightly more fats, primarily from avocado, macadamias, coconut oil and butter; no significant changes in my produce consumption, as I was already fairly low-carb.

As for exercise, at the same time that I started a paleo diet, I started weight lifting again. My experience is that weight lifting is VERY beneficial for my rheumatoid arthritis - likely every bit as crucial as diet; in a future post, I'll discuss more. . . I started out with pretty low weights, but seven years later, I am lifting literally three times as much weight as I was in the beginning (woot!); lifting sessions are typically 20-30 minutes in duration. I also started mountain biking again about four years ago. I ride or lift, on average, four to five days a week. In the deep winter, when the local trails are trashed due to weather, I mostly lift with an occasional ride here and there when the ground is frozen solid. In the summer, I mostly ride, with one or two weight lifting sessions a week. Also, I'd like to note for anyone interested, in shifting my diet toward nutritional ketosis I did not experience any noticeable difference in my exercise performance.

On to the numbers!

Total Cholesterol

2014 2015 Reference Range

186 198 100-199

LDL

2014 2015 RR

87 108 0-99

VLDL

2014 2015 RR

17 11 5-40

HDL

2014 2015 RR

82 79 greater than 59

T. Chol./HDL Ratio

2014 2015 RR

2.3 2.5 0.0-4.4

Triglycerides

2014 2015 RR

86 54 0-149

Glucose

2014 2015 RR

101 103 65-99

Hemoglobin A1c

2014 2015 RR

5.4           5.5            4.8-5.6

Footnotes found in my blood work:

**According to ATP-III Guidelines, HDL-C greater than 59 mg/dL is considered a negative risk factor for CHD (coronary heart disease).

**T.Chol./HDL Ratio
    CHD Risk
    1/2 Average Risk    Men-3.4   Women-3.3
          Average Risk    Men-5.0   Women-4.4
    2X Average Risk    Men-9.6   Women-7.1

**Hemoglobin A1c
    Increased risk for diabetes: 5.7 - 6.4

Diabetes: greater than 6.4

So, I'm thrilled with the lower triglyceride and VLDL numbers. HDL is still nicely in the very high numbers, keeping my Total Cholesterol/HDL ratio low. The LDL is outside of the lab reference range, but still below the lower target number of 130 used by the insurance company, so I wasn't penalized for that; it's a shame that they don't include HDL or the Total Cholesterol/HDL ratio in their scoring. I was penalized for having high blood glucose. I'm not terribly thrilled with the glucose number, although such numbers are not unusual for those who are very low carb (VLC) and/or in nutritional ketosis. Peter, Mark and Robb have all blogged about this phenomena.

It is my understanding that this can be 'fixed' by eating a more moderate carbohydrate diet for a short period, which could be a strategy for next year's blood work to ensure I stay within the insurance company's target score and don't end up getting nailed with higher premiums. I'm well within the overall target score this year, so there's that. . . On the other hand, I would have expected the A1c number to be a bit lower, and the elevated blood glucose still gives me the willies. . . I know Dr. Terry Wahls advocates a ketogenic diet for a variety of reasons - time to reread that section of her book and confirm whether I want to continue with nutritional ketosis or drop back to my 'normal' low-carb paleo diet.

In any case, Happy Spring all! The local trails are finally in good shape and although the weather isn't quite so warm as last weekend, the sun is out - I'm off to ride!

"The formula for weight loss sounds simple: You need to burn more calories than you take in. That usually means moving more and eating less. But does the thought of cutting back on what you eat leave you, well ... hungry?"

This is a direct quote from an email I recently received from my insurance company, accompanied by an article explaining that reducing my caloric intake by just a few hundred calories a day will help me lose those unwanted extra pounds. Oh, really? - well, it depends. . . My insurance company is not the only one bringing up calories in recent months; Mark's Daily Apple had a great post about 7 Common Calorie Myths We Should All Stop Believing and just today, a post on Robb Wolf's site asks, Do Calories Even Matter? And, for a not so recent post about the almighty calorie, Gary Taubes' post, What would happen if. . . ? Thoughts (and thought experiments) on the calorie issue.

Look, it IS true that reducing calories (see the Twinkie Diet), or tons of exercise, or both (see Biggest Loser) can reduce your 'weight', but what happens when you can't fight your body's need for 'food' any longer, or when you have health conditions that preclude hours of vigorous exercise (or, you know, you work for a living instead of living at the Biggest Loser enclave)? And what kind of 'weight' are you losing? Many conventional weight loss plans often reduce muscle mass right along with fat mass - maybe not such a good idea. And what happens when you go back to eating (and exercising) in the way you always have? Aaaaand, while dropping some weight may reduce the stress on your arthritic joints, if your focus is exclusively on counting calories, are you getting the nutrition to build healthier joints?

People like to measure things - how cold (or hot) is it today? How many miles to grandma's house? How much money is in the bank? How many calories are there in this meal? But we need some context in what we measure - If it's 35 degrees outside, am I dressed appropriately? Am I just standing around or am I doing vigorous exercise? Am I walking to grandma's house? Or am I driving there? Flying? Did I just deposit my paycheck in the bank? Or did I just pay all my bills? The same context is important when it comes to calories; it is too simplistic to reduce calories in/calories out (CICO) to a simple mathematical equation.

I recently read a discussion on a cycling forum about weight loss. It was interesting (and occasionally highly entertaining) to read through the opinions of a diverse group of people whose only common denominator is their obsession with two wheels (and if you think that a group of people whose hobby directly relates to physical activity don't struggle with their weight, think again!). There were a number of proponents of the conventional calories in/calories out weight loss model (cycle more, eat less!!), and a surprising number (at least to me), that advocated for a 'paleo diet', as well a few people who claimed weight loss success using supplements (or thought some illicit drugs might be in order). There were a couple of real gems, in my humble opinion; below is one, paraphrased for context. . .

"Calories are a unit of energy, just like a joule is.

As such calories are not ingested, processed and stored. A vast array of simple and complex compounds are ingested and metabolized and each of these have an associated energy gain which can simplistically be related to the caloric value of the food. It is massively simplistic and in some cases not at all relevant, hence the discussion here and how different foods will aid weight loss better, but it's been taken as a standard because the concept is easy for people to understand and generally is applicable when deciding total amounts of food to eat.

It seems a nit-picking point, but it isn't. Two foods with the same caloric value can be metabolized in a vastly different way and have a very different impact on the body.

As for metabolism being a simple concept. Errr... No."

To repeat, 'as for metabolism being a simple concept, errr. . . No'. Below is a 'simple' diagram of metabolism (woe-is-me, I remember memorizing some of these pathways in college). Please note, the word 'calorie' is not in there. . .

If this diagram seems complicated, think of all the complex structures you body is busily building and rebuilding, over and over and over, ad nauseam. To quote Taubes, "the mantra that ‘a calorie is a calorie is a calorie' serves only to direct attention away from the meaningful characteristics of the macronutrients in our diets...". What is the purpose of eating after all? To keep the number of calories under an arbitrary number based on your size, sex and amount of physical activity, or to provide your body with the nutrients it needs to maintain a fully functioning h. sapiens sapiens?

So, what has/is working for me?

A low calorie/high exercise regimen worked to get my weight down to around 115 in my twenties. Of course, by my thirties I had rheumatoid arthritis, irritable bowel syndrome, cystic acne and my weight had ballooned to about 190, so I guess maybe rice cakes and jogging (and later biking), wasn't entirely. . . optimal. As the weight piled on, I tried. I really tried; over the years, more biking, stair-master, aerobics, low-fat, low-cal, vegetarian. Getting 'the shakes' and brain fog, signs of blood sugar dysregulation, was an almost daily occurrence. I'd lose a few pounds, gain back those and five more. It was maddening, and I felt like such a failure. Flash forward to the adoption of a paleo/primal diet and intermittent fasting, combined with moderate weight lifting. Over a period of years, my rheumatoid arthritis and IBS improved and my weight dropped to around 125 (based on the scale at the doctor's office, as I didn't own a scale at this time). No over night magic, but steady progress. I didn't count calories. I didn't count carbs. I ate nutrient dense meals of meat/fish/fowl and vegetables; no processed food, no grains, no legumes. Regularly planned 'cheat' meals. Sometimes my workouts were gung-ho, sometimes they were half-assed. Nonetheless, I had life changing results.

Having achieved these life changing results, I got a bit cocky. I began mountain biking, stopped using intermittent fasting and became less stringent with my paleo/primal food template . . . and over a period of years, I regained around fifteen pounds (evidence, if I needed it, that up to two hours of vigorous 'cardio' four days a week, plus some weight lifting, won't do a darn thing to keep my weight stable) and I began having more significant trouble with my IBS (I also attribute this to a bout of severe food poisoning and antibiotic treatment). So, I bought a scale and rededicated myself to quality paleo food and. . . nothing happened; I could NOT make a single pound budge. Maybe because I'm now in my forties, maybe because my gut flora got all out of whack, maybe because the stars were no longer aligned; I just don't know. What I DO know is that by switching to a ketogenic paleo template with a daily (most of the time) 16 hour fast (Wahls Paleo Plus ring a bell?), I've gone back down eleven pounds (only four more to get (back) to 125). Not such a big change really; slightly (very slightly) less protein and slightly more fat (think avocado, macadamias, coconut oil) in my basic no grains, no legumes, no processed food, nutrient dense meat/fish/fowl and vegetables meal plan. Again, I'm not counting calories, or carbs, or for that matter, grams of fat (although I do confirm ketosis with urine test strips); sometimes my work outs are gung-ho, sometimes they're half-assed, and now that it's winter, I miss more days mountain biking than not. . . the body is a living system, not a static machine and I'm still learning.

A final thoughtful gem from the cycling forum:

"You've still missed the point. "Weight loss" is what? The loss of fat? The loss of muscle? Both? Going to the toilet? Sweating?

Weight gain is what? Adding fat, adding muscle, ingesting food/water?"

It's all about context. . .

In honor of Old Man Winter, and the snow currently falling outside my window, some pictures from the winters I've spent here in Missouri.