Soldiers improve their physique on a ketogenic diet

Adapted from Military Medicine January 2019 by Richard Al LaFountain et al of Ohio State University.

This is the first study of a ketogenic diet in military personnel. Daily ketone monitoring was done to personalise the diet. 29 subjects from various branches of the military took part over the 12 week study.

15 self selected to go on the ketogenic diet (KD) monitored by blood ketones daily. 14 continued their mixed diet (MD). Various measurements were done at the start and end of the programme.

All of the KD group were in ketosis throughout the 12 weeks as assessed by beta-hydroxybutrate levels. The KD group lost 7.7kg more (range -3.5 to -13.6kg) despite no calorie restriction. They lost 5.1% body fat (range -0.5 to -9.6%). 43.7% was visceral fat (range – 3.0  to – 66.3%) and had a 48% improvement in insulin sensitivity. There were no changes in the MD group.  There were no changes between the groups in aerobic capacity, maximal strength, power and a military specific obstacle course.

The authors conclude that this was a very well accepted intervention which showed remarkable improvements in body composition and weight without compromising physical performance in exercise training.

In the USA two thirds of active military personnel are overweight or obese which mirrors the general population. Nearly three out of four young people aged 17-24 fail to qualify for military service mainly due to obesity and failure to meet fitness standard thus posing an impending recruitment crisis.

The military usually follow the USDA’s dietary guidelines that advocates low fat, high carbohydrate foods. Americans have followed these recommendations for decades and have seen a marked rise in obesity at the same time. A diet that emphasises carbohydrate has the effect on suppressing fat oxidation and the production of ketones. Over half of active military personnel report drinking sugar and caffeine containing energy drinks in the past month.

Ketones produced while following a ketogenic diet have been shown to improve fat oxidation, enhance gene expression, inflammation, antioxidant defense and  healthspan. Fat loss without the explicit need to restrict calories is a benefit. Reversal of metabolic syndrome and obesity occurs. Previous studies have shown no detrimental impact on endurance and resistance training performance. The study was done in the military to see if this was a feasible approach.

The success of a ketogenic diet depends on commitment so we did not randomise the subjects. Both groups took part in identical physical training that emphasised strength and power.

Participants were recruited from the Ohio State Reserve Officer Training Corps and other local groups with a military affiliation.  We wanted people as similar as possible to the demographics of serving soldiers regarding age, sex, race and body mass. Participants were excluded if they had had previous experience of a ketogenic diet, were over 50, had certain illnesses, conditions, medications or allergies or who could not exercise safely.

The KD group were coached and were provided with unlimited frozen, pre-cooked meals and grocery supplies.  Carbohydrate was limited initially to 25g per day and protein to 90 g/d until ketosis occurred. Thereafter they could increase the amounts in their diet provided they stayed in ketosis. They were encouraged to use salt.  Carbohydrate was targeted at less than 50g per day including non starchy vegetables, nuts, seeds, selected fruit and berries. Protein goals were 0.6 – 1.0g g/kg of lean body mass. Total energy intake was not restricted. Non starchy vegetables and fats were encouraged to reach satiety. Alcohol over 2 drinks a day was discouraged in both groups.  Participants checked their blood ketones every morning and sent pictures of their readings to the research team.

The mixed diet group had a minimum consumption of 40% dietary calories from carbohydrate.  All participants met with registered dieticians and were encouraged to eat to satiety with no specific caloric limit. Dietary supplements were not allowed.

All groups undertook a progressive resistance training programme two days a week for an hour at a time. They had one additional cardio training session a week consisting of running and body weight circuit training for at least 30 minutes. Each resistance training session ended with 15 minutes of whole body, high intensity circuit training.

Body mass and body composition was measured by DEXA. Fat was assessed by MRI. Indirect calorimetry was used to evaluate resting metabolic rate and the respiratory exchange ratio.

The most noteworthy result was a spontaneous reduction in energy intake resulting in a uniformly greater weight loss for the ketogenic group.  The visceral fat was also markedly reduced which leads to a reduced risk for insulin resistance and cardiometabolic disease.  Insulin sensitivity improved in the ketogenic group.

Normalisation of weight is important for soldiers because non combat musculoskeletal injury is 33% more common in this group.

Subjects in this study were overweight but not obese, so the weight loss effect could be expected to be even more in obese subjects.  Release of fatty acids and ketones are likely the cause of the satiety effect leading to less hunger. The weight loss in the ketogenic group was 80% from body fat mass.  44% of the fat lost was from the viscera, largely in the middle of the body.

Because the subjects decided what diet they would follow, selection bias can’t be ruled out. The KD  group was also slightly heavier at baseline than the MD group.  The two women in the KD group responded similarly to the men.

 

 

 

 

Type Ones get near normal blood sugars on very low carb diets

Adapted from Management of Type One Diabetes with a very low carbohydrate diet by Belinda S Lennerz et al. Pediatrics Volume 1 number 6, June 2018.

Exceptional glycaemic control of type one diabetes mellitus with low rates of adverse events was reported by a community of children and adults who consumed a very low carb diet. This study was done by recruiting patients via an online survey. Their medical records were then used to confirm their results.

Of the 316 respondents, just over a third were parents of diabetic children. The mean age of diagnosis was 16 years and the duration of diabetes was a mean of 11 years. The mean time of following a VLCD was just over 2 years. The mean daily carb intake was 36g. The mean HbA1c was 5.67%. Only 2% of the respondents reported diabetic hospitalisations. 4 admissions were for DKA and 2 for hypoglycaemia.

In the USA the average HbA1C for type one diabetics is 8.2%.  The ADA target to reduce complications is set at under 7.5% for children and under 7% for adults. Only 20% of children and 30% of adults reach these targets.

A major difficulty is achieving post meal blood sugar targets. The carbohydrate load has the greatest influence on this. A VLCD is regarded as between 20 and 50g of carb at each meal or between 5-10% of total meal calories from carbohydrate. Some practitioners worry about advising diabetics about VLCD because of concerns about DKA, hypos, lipid problems, nutrient deficiency, growth failure and sustainability.

The study was approved by the Boston Children’s Hospital.  The recruitment group were people who were following Dr Bernstein’s Diabetes Solution. They came from the USA, Canada, Europe and Australia. They were all confirmed as having type one diabetes from their medical records.

Symptomatic hypoglycaemia was reported by 69% of the participants but severe hypos were rare. Most people had 1-5 episodes of mild hypos a month.

Most people had the characteristic low triglycerides, high HDL, high total cholesterol and high LDL pattern.  The average trig/hdl ratio was 1:1 indicating excellent cardiometabolic health. BMI was also lower than population averages for age. The DCCT covered 1441 adolescents and young adults and the factors that showed the greatest effect on cardiovascular risk were: HbA1c, then trigs, then LDLc.

The commonly reported growth deceleration noted with type one diabetes is generally thought to be due to poor blood sugar control.  In this study group however the children’s height were modestly above averages for age and gender.

A few participants deliberately did not disclose their low carb diets to their health care providers due to concerns about being criticised, pressured to change behaviour or accused of child abuse. Although 49% of participants thought that their health care provider approved of VLCDs, a robust 82% of the health care providers said they did.

We don’t know how generalisable the findings in this study could be. This group may be particularly well motivated and may be pursuing other health related behaviours such as physical activity. None the less,  the level of glycaemic control and low rates of DKA and severe hypos revealed by this study break new ground in research into diabetes management for type one diabetes.

 

 

 

RCGP: Adapting diabetes medication for a low carb diet

Adapted from RCGP July 19 Adapting diabetes medication for low carbohydrate management of type two diabetes by C Murdoch et al.

This topic has been well covered in our book but has been reviewed in this article. 

Type two diabetes can be reversed by a low carb diet. Changes in medication need to keep pace with lowered blood sugar levels that result. A low carb diet can range from under 30g to 130g of carb a day.  Blood pressure medication also often needs to be reduced or stopped as lower blood pressure results from a reduction in insulin resistance.

Sulphonylureas, meglitinides and insulin all reduce blood sugar and if not reduced appropriately can result in hypoglycaemia.  It is reasonable to cut the dose of these by 50% when a low carb diet is started. Once the diet is stabilised the levels can be increased if this is necessary. If a patient has very high blood sugars eg HbA1C of 10% or more then a reduction of 30% can be considered initially. As more weight is lost or more carb is cut from the diet, further reductions can then be made. Some patients will be able to stop insulin and oral hypoglycaemics entirely as progress is made.

Some patients have latent autoimmune diabetes and although they can reduce their doses, their insulin must be maintained at some level. These patients can often be identified because they developed type two diabetes when they were thin.

Some patients who may need to stay on some insulin have had type two diabetes for many years and have ceased to make any pancreatic insulin. (Secondary beta cell failure).  My comment:  Users of sulphonylureas eg Gliclazide over five years are prone to this problem.

It is important to provide plenty of blood glucose testing strips to patients over the transition so they can let you know if they are experiencing hypos.

GPs can refer to endocrinologists for advice over patients who are giving concern.

Flozins also known as SGLT2 inhibitors increase the risk of ketoacidosis in patients who have significant pancreatic insufficiency.  The ketoacidosis is hard to recognise because the blood sugar is often normal or only very slightly raised. The person just feels ill and may vomit. My comment: in my experience this effect is difficult to predict but usually occurs in the first week or two of treatment. Low carb diets of below 30g-50g of carb a day also produce dietary ketones so can muddy the waters even more. Therefore is someone is on a flozin and starts a low carb diet it is best to suspend the flozin. They may not require it after a while on a low carb diet in any event.

Commonly used drugs that do not give any risk of hypoglycaemia include Metformin, Glutides, Glitazones, Gliptins and Acarbose.

About a quarter of people on metformin get diarrhea and need to go on the long acting version or stop it altogether.  Because acarbose is meant to help block starch and this is eliminated on a low carb diet, this drug can be stopped.  Glutides, Glitazones, Gliptins can be stopped when blood sugars are at a satisfactory level.  My comment: The target blood sugar will vary from patient to patient. You can see more about this in my PHC talk on you tube or in our book.

 

 

 

#LowCarb Vegetarianism and other adventures

meat-free alternatives Maybe it’s the Extinction Rebellion folks gluing their hands to pavements, disrupting flights and parking their uncooperative crusty* posteriors on roads throughout central London.

Or it could be the underlying anxiety about eating meat that has always bothered me since I took it up again after more than 20 years of vegetarianism. But lately I have drastically cut down on the amount of it I’m eating and embraced the substitutes.

Vegetarianism and particularly veganism aren’t natural fits with a low-carb diet, the one I follow because I believe it’s the best one for helping people with type 1 and type 2 diabetes manage their blood sugar levels. Heck, the good Doctor Morrison and I even wrote a book about it!

Quorn slices

But the meat substitutes have come much further than the last time I ate them. Quorn makes decent fake ham slices. Cauldron sausages and marinated tofu work for me too—all of them low carb, though not as low-carb as the real thing. Even the Diet Doctor—the best source of everything you need to know about a low-carb diet in general—recognises that many people do want to follow a low-carb diet that they can square with their conscience and the website offers low carb vegetarian and even vegan plans these days.

While I question some of the health claims people make for a plant-based diet (and I’m picky about the word being used to mean ‘veganism’—I’ve always based the bulk of my diet around vegetables), poor Mama Earth’s resources will run out far too quickly if meat consumption continues at its current levels.

As I have no children, I can tick that big box on the green credentials list but the other two are eating a plant-based diet and not flying anywhere. As someone who’s not that fussed about travel, the latter might be easily achieved too. That just leaves me with what I choose to eat. As I don’t do absolutes any more, opting to be a vegetarian with limited dairy most of the time is what appeals.

Low-carb vegetarian recipes

How about you? Have you changed your diet because of environmental concern s or do you plan to? We do have veggie options on our website if you are looking for low-carb meat-free recipes. They include low-carb curried cauliflower cheese, aubergine and pepper parmigiana, baba ghanoush, Tofu with teriyaki sauce and crustless spinach and feta quiche.

*As Boris Johnson called them. Maybe he was attempting ‘wit’ as a distraction from the chaos he is in midst of creating in the UK.

Diet doctor: Type one and women’s videos

A year ago I was interviewed by Diet Doctor and after quite a wait, I’m delighted so say that my video interviews are now available at their site.

The subjects are tips for self management for people living with insulin dependent diabetes  and addressing women’s issues with type one and type two diabetes.

The videos are in the MEMBERSHIP section.

You can access these by joining the site. You can take on a free months trial and decide if you wish to continue or not after that.

 

Katharine.

 

 

 

Matthew’s Friends: a lifeline for epileptic patients

The charity Matthew’s Friends was set up by Emma Williams whose son Matthew got a great improvement in his epilepsy which did not respond to drugs but did respond to a ketogenic diet.

The charity aims to promote the ketogenic dietary option as an adjunct or alterative to drugs in children or adults whose epilepsy control is sub optimal. The hassle of following the diet often becomes much more preferable to facing a daily struggle with unpredictable and dangerous fits.

The website, Matthew’s Friends#KetoKitchen You Tube channel gives free ketogenic recipes, demonstrations and tutorials, which can be a great help to those embarking on ketogenic or low carb diets, including many diabetics. 

Professor Helen Cross from Great Ormond Street Hospital writes: Epilepsy affects 1% of all children, and in 25% of cases  there are continued fits despite considerable effort with medication. This can affect physical and mental ability, learning and behaviour. This not only affects the child but their family. The ketogenic diet has been used for almost one hundred years to treat epilepsy. There are different versions of the diet. The long chain triglyceride diet, the more liberal medium chain triglyceride diet, the modified Atkins and Low Glycaemic index diet. The best diet for an individual will be developed with the help of qualified and trained ketogenic dieticians in conjunction with the family. Such help is essential. In 60% of people who are resistant to anti-epileptic drugs, they respond, at least  to some extent to a ketogenic diet.

A three month trial of the ketogenic diet is advised to see if there is a response or not.In many cases, the response is so marked that medication can be stopped entirely. Obviously, direct clinical supervision is mandatory.

Matthew’s Friends can advise parents or people who would like to improve their epilepsy and provide contacts and materials to get started on an appropriate ketogenic diet. They are always grateful for donations to further their work.

Diabetes Digital Media launch low carb app endorsed by NHS

Adapted from The Times  January 6 2019 by Peter Evans

The better late than never NHS has finally endorsed a phone app that helps diabetics stick to a low carb diet.

Diabetes Digital Media based in Warwick have had their app, The Low Carb Program, accepted by the NHS apps library.  DDM has partnered with Ascensia Diabetes Care to allow patients free use of the app when recommended by GPs.

DDM was founded by Arjun Panesar and Charlotte Summers. Their company is on track to make sales of 1.7 m this year.