Kris Kresser: Everything you need to know about a ketogenic diet

A Complete Guide to the Keto Diet
by Chris Kresser
Published on April 2, 2019
Ketogenic diets are currently all the rage. Seemingly every health personality has an opinion on the ketogenic diet, commonly referred to as “keto.” Some tout it as a cure-all for everything from diabetes to cancer, while others express skepticism or disagree with some aspects of the diet.

The keto diet could help alleviate conditions like obesity and type 2 diabetes and even impact the progression of some types of cancer, but it isn’t for everyone.

It’s understandable that you may be wondering how to sort out the facts and interpret the latest research. Who is a good candidate for keto, and who should avoid it? How does someone successfully adhere to a ketogenic diet? In this article, I’ll answer these important questions and others so you can make an educated decision about whether keto is right for you.

What is the keto diet?
Nine conditions that respond well to keto
Who should avoid the diet
The keto time frame
Three steps to starting keto
13 tips and tricks
What to expect on keto
What Is the Keto Diet?
The ketogenic diet is a high-fat, moderate-protein, low-carb food plan. The typical macronutrient ratios are 60 to 75 percent of calories from fat, 15 to 30 percent of calories from protein, and 5 to 10 percent of calories from carbohydrates.
By strictly limiting dietary carbohydrates, the ketogenic diet encourages the body to switch from using glucose as a primary fuel source to burning body fat and using ketones for fuel. This metabolic switch has a variety of beneficial effects on the body, ranging from fat loss to improved brain function.
The keto diet could potentially address a number of health conditions, such as obesity, type 2 diabetes, and even cancer. Check out this article for more information on who should try keto—and who shouldn’t—and get tips to help you. #lowcarb #nutrition #chriskresser

A ketogenic diet differs dramatically from the carbohydrate-heavy Standard American Diet. When you eat a carbohydrate-rich meal, the ingested carbs are broken down into glucose. Glucose is then shuttled into cells by insulin, where it is used for energy production. The constant consumption of a high-carbohydrate diet causes the body to rely on glucose (sugar) for fuel, while rarely tapping into fat stores for energy. A ketogenic diet does just the opposite. It forces the body to turn to fats for fuel. A keto diet encourages the production of ketones, small water-soluble compounds, and the “burning” of fatty acids in adipose tissue (fat cells) for energy. Ketones are unique in that they are rapidly taken up by tissues and broken down to yield ATP, the primary energy currency of the human body. The process by which the body switches to using ketones for energy is referred to as “nutritional ketosis,” while the process of tapping into your body’s fat stores is termed “fat adaptation.”

Choosing the right diet can be a difficult process of trial and error. Health coaches support people in finding the best diet for their bodies, lifestyles, families—wherever they need encouragement in discovering the right path, etc. As a coach, you learn to ask the questions that help people figure out whether a diet is the right fit for them. This not only helps them make a good choice but minimizes the time they spend with diets that don’t work well for them.

Health coaches can also help people navigate their chosen diets, like the ketogenic diet. As an example, some people may need a little extra push getting their bodies to transition to using ketones. If you are finding it difficult to get into ketosis, a health coach can help you navigate that process.
How do health coaches do this? In our ADAPT Health Coach Training Program, you learn about a variety of diets—including the ketogenic diet—how they work, who they work well for, and how to support people in making diet transitions. Visit our health coach training program page to find out more.

The ADAPT Health Coach Training Program is an Approved Health and Wellness Coach Training & Education Program by the National Board for Health and Wellness Coaching (NBHWC).
Nine Conditions That Are Ideal for Keto
The ketogenic diet offers many health benefits, but it isn’t right for everyone. Read on to learn who stands to benefit the most from keto and which conditions tend to respond the best to the diet.
1. Obesity
Disturbing statistics indicate that weight problems have reached epidemic proportions in the United States, with nearly 72 percent of American adults 20 and over categorized as overweight or obese. (1) The mandate that overweight and obese individuals should merely “eat less and exercise more” is failing miserably; it does little to correct the underlying metabolic disturbances driving obesity, trapping people in a vicious cycle of weight loss and regain. However, all hope is not lost! The ketogenic diet is emerging as a powerful, sustainable tool for weight loss in overweight and obese individuals.
A growing body of research indicates that ketogenic diets are more effective than low-fat diets for sustaining long-term weight loss in obese adults. (2, 3) Furthermore, the weight loss observed on a ketogenic diet is primarily visceral fat, the hard-to-lose fat located deep in the abdominal cavity; lean body mass, on the other hand, is preserved. (4)
A ketogenic diet may also benefit obese children. A study that placed obese children on a ketogenic diet for six months observed significant decreases in body fat, waist circumference, fasting insulin levels, and HOMA-IR, a marker used to detect insulin resistance. (5)
The ketogenic diet facilitates fat loss by increasing the efficiency of fat oxidation (the process by which fat is “burned” for energy), suppressing hunger hormones, and providing the body with plenty of satiating dietary fat and protein, thus decreasing total energy intake. (6)
For those who do not wish to stay on the ketogenic diet long term, a cyclic ketogenic diet alternated with a nutrient-dense, whole foods diet can also lead to successful long-term weight loss. (7) I’ll cover the cyclic ketogenic diet in more depth shortly.
2. Metabolic Syndrome
Over one-third of Americans have metabolic syndrome, a constellation of complications including increased blood pressure, elevated blood sugar, excess abdominal fat, and abnormal triglyceride and cholesterol levels that significantly increase one’s risk of heart disease, diabetes, and stroke. (8) The conventional treatment of metabolic syndrome typically involves cholesterol-, blood sugar-, and blood pressure-lowering medications, along with vague advice to “eat better.” Given that heart disease is still the number one cause of death in the United States, that diabetes is considered to be at epidemic proportions, and that strokes disable or kill someone every 40 seconds on average, this treatment paradigm leaves much to be desired. (9)
Fortunately, patients have an alternative—a ketogenic diet. Research indicates that a ketogenic diet improves multiple aspects of metabolic syndrome, inducing significant reductions in body fat percentage, BMI, hemoglobin A1c levels, blood lipids, and blood pressure. (10, 11, 12) The ketogenic diet produces these beneficial effects by reversing the pathological processes underlying metabolic syndrome, including insulin resistance and chronic inflammation.
3. Type 2 Diabetes
Ketogenic diets represent a far more effective strategy for managing type 2 diabetes than the American Diabetes Association’s high-carb, low-fat dietary guidelines. Unlike the ADA’s guidelines, a ketogenic diet significantly reduces blood sugar, hemoglobin A1c levels, waist circumference, and triglycerides in diabetic individuals. (13) Most importantly, research indicates that the diet is sustainable for diabetic patients and that the beneficial changes can be maintained over the long term. (14)
4. Polycystic Ovary Syndrome (PCOS)
Between 5 and 10 percent of women in the United States have polycystic ovary syndrome (PCOS), a disorder characterized by insulin resistance, menstrual irregularities, hyperandrogenism, overweight, and obesity. (15) A ketogenic diet improves fertility in women with PCOS by improving insulin resistance, promoting weight loss, and inducing ovulation. (16)
5. Neurodegenerative Diseases
A great deal of exciting research is emerging regarding the application of a ketogenic diet in the treatment of neurodegenerative diseases, including Alzheimer’s and Parkinson’s disease. (17) Neurodegenerative diseases are characterized by brain insulin resistance, a condition that starves neurons of the glucose they normally need to function correctly. Scientists have found that ketones are an excellent alternative fuel for the insulin-resistant brain. In addition, ketones reduce brain oxidative stress and mitochondrial dysfunction, two significant factors in the neurodegenerative disease process.
Animal research indicates that a ketogenic diet reduces levels of brain amyloid-beta, a misfolded protein that contributes to Alzheimer’s disease, while also restoring mitochondrial function and improving learning and memory. (18, 19, 20) Although fewer studies on a ketogenic diet have been done in humans with Alzheimer’s disease, a recent trial found a ketogenic diet to be both safe and effective for mild Alzheimer’s disease. (21)
Preclinical research suggests that a ketogenic diet may also benefit those with Parkinson’s disease. In animal models of Parkinson’s, a ketogenic diet improves motor function, and in humans with Parkinson’s, it improves nonmotor symptoms such as daytime sleepiness and cognitive disorders. (22, 23) While more research is needed, a ketogenic diet may be a powerful intervention well worth a try for both Alzheimer’s and Parkinson’s patients.
6. Traumatic Brain Injury and Epilepsy
Traumatic brain injury (TBI) is an injury caused by a blow, bump, or jolt to the head that significantly impairs brain function. TBI is common in military personnel, car accident survivors, and athletes involved in contact or high-risk sports. If left untreated, TBI can cause severe impairments in thinking, memory, and emotional regulation. Interestingly, a ketogenic diet may be an effective strategy for reducing the harmful effects of TBI.
A ketogenic diet promotes healing of the brain following TBI by increasing the activity of genes genes involved in energy metabolism, stimulating the generation of new mitochondria, and inhibiting the production of damaging reactive oxygen species in the brain. (24) In animal models of TBI, a ketogenic diet reduces cerebral edema and neuronal cell death while improving behavioral outcomes. (25, 26) While individual success stories of people using a ketogenic diet for TBI are easy to find on the internet, formal clinical trials are still needed.
Compared to TBI, the amount of scientific literature documenting the beneficial effects of a ketogenic diet for epilepsy is vast. The ketogenic diet was first introduced as a therapy in the 1920s, when doctors learned it could successfully treat seizures in children with refractory epilepsy. (27) Interest in the ketogenic diet waned when antiepileptic drugs were introduced in the 1960s and ’70s; however, the ketogenic diet has experienced a recent resurgence in popularity in the epilepsy community, particularly among those suffering from drug-resistant epilepsy.
The ketogenic diet exerts antiepileptic effects by improving energy metabolism in the brain and reducing brain oxidative stress. Fascinating new research suggests that the antiseizure effects of the ketogenic diet are also mediated by modulation of the gut microbiota. (28) Consumption of a ketogenic diet increases the levels of bacteria that produce GABA, the brain’s primary inhibitory neurotransmitter; this shifts neurotransmission towards inhibition rather than excitation, thus preventing neuronal hyperexcitability and seizure onset.
7. Digestive Disorders
A high carbohydrate intake can exacerbate irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD) by feeding opportunistic and pathogenic bacteria in the gut. (29) These microbes ferment dietary carbohydrates, producing gases that increase intraabdominal pressure, a driving force behind acid reflux and GERD. The gas manufactured by these bacteria also contributes to bloating, abdominal pain, and diarrhea in IBS.
How can a ketogenic diet help with IBS and GERD? By significantly reducing dietary carbohydrate load, a ketogenic diet provides less fermentable substrate for gut bacteria, reducing the amount of gas produced in the small intestine. Several small studies indicate that a ketogenic diet improves abdominal pain, stool frequency, and reflux in patients with IBS-D and GERD, respectively. (30, 31) However, it is important to note that the long-term effects of a low-fermentable-carbohydrate diets, including the ketogenic diet, on gut bacteria remain to be seen. Our beneficial gut bacteria also require fermentable carbohydrates to survive, so it’s possible that the ketogenic diet could reduce their numbers. This is why I highly recommend following a cyclic ketogenic diet rather than a long-term, strict ketogenic diet. I’ll provide more information on that topic shortly.
8. Skin Conditions
A ketogenic diet may seem like an unlikely approach for treating skin issues. However, keto addresses several of the physiological mechanisms underlying dermatological issues, particularly acne and psoriasis, and can therefore help people correct the root cause of their skin conditions.
Insulin is a crucial driver of acne due to its effects on hormones, sebum production, and inflammation. By reducing insulin, the ketogenic diet may correct hormone imbalances, excessive sebum production, and inflammation, thereby alleviating acne. (32)
High blood sugar promotes psoriasis by increasing levels of a protein that causes inflammation. A ketogenic diet corrects hyperglycemia and may lower the level of this protein, resulting in the amelioration of psoriasis. (33)
9. Some Forms of Cancer
Some of the most exciting research on the ketogenic diet pertains to its applications in the treatment of cancer. A rapidly growing collection of animal studies indicates that the ketogenic diet has anticancer effects in malignant glioma, neuroblastoma, prostate cancer, and colon cancer. (34) In humans, a ketogenic diet has been found to work synergistically with antineoplastic agents in the treatment of malignant glioma, a common primary brain tumor that is notoriously difficult to treat. (35) Several small studies indicate that the ketogenic diet improves body weight and blood profiles while reducing a marker for tumor progression, TKTL1, in patients with breast, prostate, colon, melanoma, and lung cancers. (36, 37)
The ketogenic diet exerts anticancer effects by inducing a metabolic shift in malignant tissues that promotes apoptosis (self-programmed death) of cancer cells, inhibiting angiogenesis (the growth of new tumor-supporting blood vessels), reducing oxidative stress and inflammation, suppressing mTOR (a protein in humans involved in the regulation of cell growth and regeneration), and increasing the sensitivity of certain cancer cell types to chemotherapy. (38)
Since a ketogenic diet can induce weight loss, clinicians should take care to ensure that adequate calories are consumed to inhibit undesirable weight loss in cancer patients.
It is crucial to recognize that not all forms of cancer will respond to a ketogenic diet.
Research suggests that cancer cells with low levels of particular enzymes (the ketolytic enzymes 3-hydroxybutyrate dehydrogenase and succinyl CoA 3-oxoacid CoA transferase) are more susceptible to the anticancer effects of a ketogenic diet. Screening a patient’s cancer cells for these enzymes may represent a valuable strategy for determining whether a ketogenic diet may be of use. (39)

Who Should Avoid a Ketogenic Diet?
The ketogenic diet is not appropriate for everyone. If you fit any of the descriptions listed below, then a ketogenic diet may have a negative impact on your health.
You Have a Genetic Condition That Affects Fatty Acid Metabolism
Since fats are consumed in large quantities on a ketogenic diet, any genetic condition that impairs fatty acid metabolism precludes the use of this diet. If you have primary carnitine deficiency, pyruvate carboxylase deficiency, or any of the other genetic conditions listed here, a ketogenic diet is absolutely contraindicated.
You’re Pregnant or Breastfeeding
While a growing fetus can utilize ketones to an extent, it still requires a steady glucose supply to support normal growth, including crucial brain development. Reduced glucose availability caused by a maternal ketogenic diet may have long-term adverse effects on infant health, including abnormal growth patterns and alterations in brain structure. (40) If you are pregnant and struggling with blood sugar issues, a low-carbohydrate diet that includes moderate amounts of nutrient-dense carbohydrates, such as fruit and starchy tubers, is a safer choice than a ketogenic diet.
You Have Gallbladder Disease or No Gallbladder
The body needs bile to break down and digest dietary fat, and the gallbladder is responsible for storing bile before its release into the small intestine. Removal of the gallbladder and gallbladder disease cause fat malabsorption and may make it difficult to follow a ketogenic diet. If you have had your gallbladder removed or have existing gallbladder disease, consult with your doctor before trying a ketogenic diet.
You’re Suffering from Kidney Disease or Kidney Stones
While preliminary research suggests that a ketogenic diet may benefit chronic kidney disease patients, caution is advised in those with kidney disease or kidney stones. (41) If you have a kidney condition, consult with your doctor before starting a ketogenic diet.
You Have HPA Axis Dysfunction and High Levels of Stress
A ketogenic diet has been observed to raise cortisol, the body’s primary stress hormone. If you struggle with high levels of stress or HPA axis dysfunction, a ketogenic diet may push your stress-response system into overdrive and cause burnout. A diet that includes a moderate intake of carbohydrates is typically a better fit for those with high-stress lifestyles or HPA axis dysfunction.
You’re a Hyper-Responder to Dietary Cholesterol
While dietary saturated fat and cholesterol do not impact blood cholesterol levels in most people, they may raise total and LDL cholesterol in a subset of the population referred to as “hyper-responders.” If you are a hyper-responder (this is something you’ll need to determine with the help of your doctor), I recommend following a Mediterranean Paleo-style diet, an approach that is lower in fat and higher in Paleo-friendly carbohydrates, rather than a ketogenic diet.
You’re an Athlete
If you participate in exercise that involves explosive movements such as jiujitsu, mixed martial arts, CrossFit, or even some rigorous forms of dance, you may benefit from a moderate carbohydrate intake rather than a ketogenic diet. Explosive movements draw on your muscles’ glycolytic capacity, which is powered by glucose from dietary carbohydrates. Endurance athletes, on the other hand, may thrive on a ketogenic diet because their respective activities can be adequately fueled by fatty acid oxidation and ketones.

How Long to Follow the Ketogenic Diet
The ideal keto diet time frame must take into account both nutritional ketosis and fat adaptation. Ketosis means your body is experiencing an acute lack of glucose and is therefore producing ketone bodies for energy. Fat adaptation, on the other hand, means your body has become adapted to burning fat for fuel.
When you first embark on a ketogenic diet, your goal is to be in nutritional ketosis consistently. Over time, as you train your body to function on fewer carbohydrates, you may enter the fat adaptation phase. While ketosis can be achieved after just a few days of the diet, at least three to four weeks of strict adherence to the diet is required in order to reach the fat adaptation state. This is also the time frame during which you’ll likely begin to notice benefits of the diet.
While some keto proponents advocate following the diet long term, a cyclic ketogenic diet may be a healthier choice.
A cyclic ketogenic diet involves carb-loading one to two days of the week, followed by a standard low-carb ketogenic diet the remaining days of the week. Cyclic keto has many benefits—it allows the body to enter a state of ketosis regularly while also satisfying carb cravings, improving sleep, and promoting a healthier balance of gut bacteria.

The Three-Step Process to Starting Keto
Step 1: Find Your Macronutrient Ratio
The goal of a ketogenic diet is to transition the body’s primary fuel supply from carbohydrate to fat, creating a state of nutritional ketosis and, eventually, fat adaptation. The degree to which dietary carbohydrates need to be reduced to reach nutritional ketosis varies from person to person. Finding the optimal macronutrient ratios for getting your body into ketosis requires some self-experimentation. I recommend playing around with the ranges listed below to find the ones that work best for you.
Possible macronutrient ranges for keto:
60 to 75 percent of calories from fat
15 to 30 percent of calories from protein
5 to 10 percent of calories from carbohydrates
I would like to emphasize that the super-high-fat, low-protein version of keto promoted by some keto advocates is not necessary for most people to obtain the benefits of keto.
Proponents of the super-high-fat, low-protein approach argue that protein kicks the body out of ketosis by supplying amino acids for gluconeogenesis (simply put, turning non-carbs into fuel); however, research indicates that the impact of dietary protein on gluconeogenesis and glucose flux is nearly negligible, making this argument irrelevant.

(42) In my practice, we have found that usual protein intakes (15 to 20 percent of calories) do not have appreciable effects on blood ketone levels. Besides, a super-high-fat, low-protein diet typically has more drawbacks than benefits—it may cause weight gain, muscle loss, fatigue, and chronic hunger. Don’t be afraid of including plenty of protein in your ketogenic diet; protein is a powerful tool that will satiate your appetite while facilitating fat loss and preventing muscle loss.
Step 2: Don’t Count Calories
I don’t recommend counting calories on the keto diet. Tracking your macronutrients, on the other hand, can be helpful. Try using an app for journaling your food intake and obtaining your ratios of macronutrients. I recommend the Carb Manager Keto Diet App.
Step 3: Regularly Test Your Ketones
To determine whether you’re in ketosis and what degree of ketosis you’re in, test your ketones each morning. Blood ketone testing is the most accurate method—I do not recommend breath or urine ketone monitoring. In our practice, we recommend the Precision Xtra Blood Glucose Meter Kit, which can be purchased on Amazon (you can buy test strips for this meter in bulk on eBay for a lower cost). Keto Mojo is another good meter with affordable test strips.
If your ketone value is above 0.5 mmol/L first thing in the morning, you’re in ketosis. However, a range of 0.7 to 2.0 mmol/L is optimal for most people. If your value is above 3.0 mmol/L, you may not be eating enough and/or should consider adding some carbohydrates back to your diet. However, in the long run, your goal should not be a specific number on the ketone meter, but an improvement in your symptoms.

13 Tips and Tricks to Help You Follow a Ketogenic Diet
Following a ketogenic diet can take some work and planning. Here are some tips and tricks to help you get into ketosis faster.
1. Eat Enough Calories and Protein
Failing to consume enough calories on a keto diet can cause fatigue and insomnia, while an insufficient protein intake promotes weight gain and muscle loss. When you first begin a keto diet, it can be helpful to track your food intake with an app such as Carb Manager Keto Diet App; this will allow you to visualize your macronutrient intake and ensure that you don’t undereat calories or protein. As I mentioned earlier, a low-protein intake is not required to obtain the benefits of keto. A sufficient protein intake (15 to 30 percent of total calories) suppresses hunger and, in most people, does not affect blood ketone levels. (43)
2. Add Supplemental Fat
Fat is the primary source of fuel on a ketogenic diet, and supplementing with specific types of fat, particularly coconut oil and medium-chain triglyceride (MCT) oil, can help you get into ketosis faster. MCT oil is unique in that it increases ketone levels in a linear, dose-dependent manner and allows for the induction of ketosis with lower amounts of total fat in the diet. (44)
If you are a hyper-responder to dietary fat and cholesterol, you may need to restrict your intake of saturated fats on keto. Instead, focus on fats such as olive oil, avocados, fatty fish, nuts, and seeds.
3. Supplement
L-leucine is a ketogenic amino acid, meaning it can be used to make ketones. Supplementing with L-leucine may help you get your body into ketosis faster.
Exogenous ketones are ketones that are ingested as a nutritional supplement. They elevate blood ketone levels but may inhibit the body’s own process of ketogenesis. (45) I consider exogenous ketones an advanced strategy for those who have already nailed down the basics of keto.
4. Drink Apple Cider Vinegar
Consuming apple cider vinegar before meals not only assists digestion but may also promote ketone production due to its content of acetic acid, a naturally occurring ketogenic compound. Try adding a tablespoon or two to water and drinking before you eat your meal.
5. Increase Your Salt Intake
The body excretes more salt on a keto diet than on a standard diet due to reductions in insulin, which normally promotes a certain degree of water retention. Once you’re in ketosis, add an extra three to five grams of Himalayan, sea, or Redmond Real salt to your diet every day. (Five grams is about one teaspoon, but that may vary depending on the type of salt and the size of the grain.)
6. Eat More Magnesium and Potassium
In addition to sodium, levels of magnesium and potassium can also drop on a ketogenic diet due to its dehydrating effect on the body. Make sure to eat plenty of magnesium- and potassium-rich foods. Some of the best keto-friendly sources of magnesium are dark leafy greens, nuts and seeds, and cacao. Keto-friendly potassium sources include spinach, kale, avocados, and mushrooms.
7. Avoid Artificial Sweeteners
Artificial sweeteners such as saccharin (Sweet’N Low), aspartame (NutraSweet, Equal), and sucralose (Splenda) are quite popular among low-carb dieters. However, concerning new research indicates that artificial sweeteners have adverse metabolic effects and may work against your keto efforts by disrupting your gut microbiota and inducing insulin resistance and weight gain. (46, 47) If you want to use a non-caloric sweetener, I recommend either stevia or monk fruit sweetener.
8. Stock Up on Keto-Friendly Snacks
Keep keto-friendly snacks on hand so that when hunger strikes, you have healthy food at the ready; this strategy will help prevent you from falling off the keto wagon and reverting to high-carb snack foods. Nuts and seeds, coconut butter, grass-fed beef jerky, and hard-boiled eggs make for easy, portable keto snacks.
9. Try Intermittent Fasting
Intermittent fasting, an eating style in which you eat within a specific period each day and fast the rest of the time, is a great way to reduce the amount of time your body needs to enter nutritional ketosis. (48) Intermittent fasting accelerates the time to ketosis by keeping insulin levels low and raising ketone levels. If you’re new to intermittent fasting, start by limiting your eating to an eight- to 10-hour window each day and fasting for the remaining 14 to 16 hours of the day (and night).
10. Decrease Your Stress
Stress is an underappreciated but significant impediment to achieving success on a ketogenic diet. High stress elevates cortisol, which stimulates the generation of glucose (gluconeogenesis) in the liver. Gluconeogenesis raises blood glucose and reduces ketone levels; together, these effects make it difficult to enter ketosis.
Try these strategies for reducing your stress:
Set aside time for rest, ideally away from your smartphone and computer
Cut down on commitments
Get plenty of sleep
Start a mindfulness practice such as meditation
Spend time in nature
Spend quality time with friends and family
11. Prioritize Sleep
Inadequate sleep will rapidly derail your keto efforts by increasing your blood sugar and levels of stress hormones. Getting eight to nine hours of high-quality sleep per night should be a priority. Maintain a regular bedtime schedule and practice sleep hygiene strategies such as keeping your bedroom completely dark at night, lowering the ambient temperature to around 67 degrees Fahrenheit, and avoiding blue light exposure a couple of hours before bed with blue light-blocking glasses.
12. Exercise
Frequent exercise depletes glycogen stores, causing your body to turn to fat for energy; this means that regular exercise can help you get into ketosis faster. Some people experience a reduced capacity for exercise upon starting keto; in this case, engaging in longer durations of low-intensity activity, such as walking, cycling, or swimming, can help you get into ketosis without causing undue fatigue.
13. Drink Plenty of Water
Within the first few days of starting a ketogenic diet, you may experience a significant loss of water weight. This occurs primarily because glycogen stores in muscle are gradually being reduced, and glycogen causes retention of water. To ensure that you don’t become dehydrated on keto, drink half your weight in ounces of filtered water every day.

What to Expect When You’re on the Keto Diet
As your body gets used to keto, you may experience some uncomfortable side effects. Here’s what to expect.
The “Keto Flu”
The first few days of keto can be difficult as your body adjusts to a low carbohydrate intake; you may experience symptoms such as brain fog, headache, insomnia, irritability, and digestive issues. These symptoms are commonly referred to as the “keto flu” and are caused by the glycogen loss, low insulin levels, and dehydration that frequently occur when you suddenly cut back on carbs. Know that these symptoms will pass, especially if you make sure to drink plenty of water, replenish your electrolyte levels, and eat sufficient protein and calories. At the most, it may take a couple weeks for the keto flu to subside, but for most people, this uncomfortable period passes within a few days.
Constipation
Constipation is a common complaint for keto dieters. There are several reasons why you may experience constipation:
You’re not eating enough fiber. It’s easy to eat lots of meat, cheese, and oils on a ketogenic diet at the expense of optimal fiber intake. Be sure to eat plenty of colorful non-starchy vegetables (broccoli, cauliflower, kale, bell peppers, mushrooms) because the fiber in these foods will keep things moving through your digestive tract.
You may need more water. As I mentioned earlier, people typically experience body water loss when starting a ketogenic diet. Your digestive tract needs water to keep fecal matter soft and moving through your intestines; if you are dehydrated, constipation is likely.
Try resistant starch. Resistant starch passes through the small intestine intact and therefore doesn’t count as a dietary carbohydrate. Instead, it travels to your large intestine, where it’s used to feed beneficial gut bacteria. Try adding a teaspoon of resistant starch, such as raw potato starch or green banana flour, to your keto smoothie each day to keep your gut happy.
Take a probiotic and eat fermented foods. The beneficial bacteria in probiotics and fermented foods help prevent sluggish digestion and promote healthy bowel function.
Reduced Thyroid Function
Research has found that a ketogenic diet decreases levels of T3, the body’s active thyroid hormone. (49) Unfortunately, this means a ketogenic diet may not be optimal for those with pre-existing hypothyroidism. If you have hypothyroidism and want to proceed with a ketogenic diet, consult with your doctor first because you may need thyroid support.
Elevated Cortisol
Research has indicated that a ketogenic diet raises the stress hormone cortisol to increase energy levels in the face of reduced carbohydrate availability. However, it is still up for debate whether this increase in cortisol is harmful or innocuous. Nonetheless, I recommend taking extra care to manage your stress while on a ketogenic diet. Getting plenty of sleep, exercising, and engaging in a regular stress-reduction practice can help you keep your baseline stress levels low and reduce the potential for chronically elevated cortisol.

BMJ: Why don’t we encourage and register the diabetics who achieve remission?

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Weighing up the benefits of registering those in remission from type two diabetes

Adapted from BMJ Louise McCombie et al 16 Sept 17

Type two diabetes now affects between 5 -10% of the UK population. This is 3.2 million people in the UK. 10% of the NHS budget is spent on treating diabetes and costs are between two and three times that of age matched individuals without diabetes. Life expectancy is six years less for people with type two diabetes.
Remission is attainable for some patients but is rarely achieved or recorded. (My comments: except in the low carbing community) The trend is for diabetes management to focus on reversible underlying disease mechanisms rather than treating symptoms and multisystem pathological consequences.
Lowering blood glucose remains the primary aim of management and drugs are the main method of doing this rather than diet and lifestyle advice. (My comment: because high carb/low fat dietary advice is counterproductive).
It has been found that weight loss of 15kg often produces biochemical remission of type two diabetes, restoring beta cell function. The accumulation of fat in the liver and pancreas impairs organ function to cause type two diabetes but is potentially reversible. If remission is achieved, the person no longer requires diabetes drugs.
The American Diabetes Association describe a partial remission as below the threshold for diabetes diagnosis. This is a hba1c of less than 6.5%/48 mmol/mol and a fasting blood sugar less than 6.9 without diabetes drugs. A full remission is described as the elimination of the criteria for impaired glucose tolerance. This means a hba1c less than 6%/42 and a fasting blood sugar under 5.6 again without the use of diabetes drugs.
A full remission will completely remove the cardiovascular risk associated with diabetes but partial remission removes a great deal of the risk and is still very much worthwhile.
We suggest that whether hba1c or fasting blood sugars are used to detect remission that these are repeated twice at two month intervals. Once in remission, a patient should be tested annually.
No study has yet been done that has reported the outcomes for diabetics in remission, but you would expect their outcomes to be much better than it otherwise would.
If a patient achieves remission, and if the Read code C10P is applied to them, they would still be scheduled for annual reviews and retinal screening programmes but would be considered non-diabetic for matters such as insurance, driving, and employment. But so far, in Scotland, only 0.1% of diabetics have been coded as being in remission.
Perhaps there are coding errors, but the possibility that type two diabetes can be reversed may not be fully understood by both doctors and patients. If patients achieve either a 10% body weight loss or 15kg, then 75-80% of them can expect to go into diabetes remission.
Physical and social environments, emotional states and self- regulatory skills are important factors affecting adherence to a weight management intervention.
It costs around £5,000 for the medical care of a person with type two diabetes but this almost doubles over the age of 65. The patient also has increasing holiday insurance costs. This is around double the usual rate for type twos and more for insulin users. Could knowledge of the advantages of weight loss act as an incentive for patients?

 

Start ’em young

 

kid

 

A survey of UK school children has shown that children as young as nine and ten are already showing signs of markers for type two diabetes.

It is known that the more screen time a child has, whether this is computer games, video games or television, the fatter they get. There is a dose / response effect.

Insulin resistance also increases and also shows a dose / response effect. The surprise is how early the changes occur.

Achiv Dis Child doi:10.1136/archdischild-2016-312016

Eric Barker: 5 Questions that will make you emotionally strong

wonder woman

5 Questions That Will Make You Emotionally Strong

Click here to read the post on the blog or keep scrolling to read in-email.

Ever been caught in the grip of extreme emotions? I’m gonna guess whatever decision you made next probably wasn’t a good one.

When we’re anxious, angry, or sad, we rarely do the smart thing. And that can seriously mess up our lives. At work, in love, or pretty much anything we do, we need emotional strength to stay cool and do the right thing.

Now dealing with the ups and downs of feelings isn’t anything new. And nor are some of the best solutions. So let’s look at what some ancient wisdom has to say about dealing with difficult emotions.

Studying Buddhist mindfulness or Stoicism can take a heck of a long time. So we’ll prune their insights down to 5 questions that can help you when emotions hijack your brain and send you into a tizzy.

First up: worrying. When your mind is filled with anxious concerns and doubts, what question do you need to be asking yourself?

“Is This Useful?”

Face it: your brain can be a pretty crazy place. All kinds of things bounce around in there. And you’re usually pretty good at culling the wacky thoughts. But then you get worried…

And your brain starts multiplying negative possibilities like crazy. And you make the mistake of taking them seriously. Every. Single. One.

Remember: you are not your thoughts. Neuroscientist Alex Korb made an interesting distinction when I spoke to him. If you were to break your arm you would not tell people, “I am broken.” But when we feel worry we’re quick to say, “I am worried.”

Your brain produces thoughts. That’s its job. But that’s not directly under your control. So just because something is in your head, doesn’t mean it’s “you”, and should therefore be taken seriously.

When I spoke to Buddhist mindfulness expert Sharon Salzberg, she said this:

I think one of the issues that we have is that we don’t necessarily recognize that a thought is just a thought. We have a certain thought, we take it to heart, we build a future on it, we think, “This is the only thing I’ll ever feel”, “I’m an angry person and I always will be”, “I’m going to be alone for the rest of my life”, and that process happens pretty quickly.
If you acted on every crazy thought that popped into your head, I can guarantee you two things:

  • There’s a blockbuster reality show in your future.
  • And not a lot of happiness.

So if you are not your thoughts, who are “you”? You’re the thing that decides which thoughts are useful and should be taken seriously.

The ancient Stoics believed that you are just your reasoned choice; because that’s the only thing fully under your control. So those worried thoughts aren’t you. The decisions you make regarding them are.

You’re not your brain; you’re the CEO of your brain. You can’t control everything that goes on in “Mind, Inc.” But you can decide which projects get funded with your attention and action.

So when a worry is nagging at you, step back and ask: “Is this useful?”

When I spoke to Buddhist mindfulness expert Joseph Goldstein he said:

This thought which has arisen, is it helpful? Is it serving me or others in some way or is it not? Is it just playing out perhaps old conditions of fear or judgment or things that are not very helpful for ourselves or others? Mindfulness really helps us both see and discern the difference and then it becomes the foundation then for making wiser choices and why the choices lead to more happiness.
If the worry is reasonable, do something about it. If it’s irrational or out of your control, recognize that. Neuroscience shows that merely making a decision like this can reduce worry and anxiety.

(To learn the 7-step morning ritual that will make you happy all day, click here.)

But maybe you’re not worried. Maybe you’re furious. But what is anger? Where does it come from? And what question can make these HULK SMASH feelings go away?

“Does The World Owe Me This?”

Anger comes from entitlement. You feel you’re entitled to something, reality doesn’t bend to your expectations and boom — you’re punching things. Or people.

Traffic is bad. You get angry. Let me translate that thought process for you: “Traffic should never cause me problems. The world owes me that.” Sound reasonable? Hardly.

Or someone doesn’t do what they said they’d do. You get angry. Now you might reply, “People should do what they say they’ll do! I have a right to be angry!”

Yes, it would be nice if people always followed through, but is that a reasonable expectation? Of course not. You know people don’t always do what they say. Now you can definitely call them out on it. You can decide to do something in response. But the anger?

That awful feeling is all yours. You had an unrealistic expectation (“People will always do what they say”) and now you’re shocked — SHOCKED! — that they didn’t.

Famed psychologist Albert Ellis (whose work was inspired by the Stoics) led a war against the words “should” and “must.” Anytime you use those words, you’re probably in for some unhappiness because you’re saying the universe is obligated to bend to your will. Good luck with that.

So the solution to anger is to ask yourself: “Does the world owe me this?”

Yeah, it’s a trick question. Because the world doesn’t owe you anything. And the more you think the world owes you, the angrier you will be. Again, it’s all about reasonable expectations. And that’s why Marcus Aurelius said:

Begin each day by telling yourself: Today I shall be meeting with interference, ingratitude, insolence, disloyalty, ill-will, and selfishness…
Not a pleasant way to start the day — that I grant you. But he was on to something. Expecting everything to go your way, let alone insisting on it, is a prescription for anger.

I know what some people are thinking: feeling you’re entitled to nothing in life seems unfair and sad. But don’t forget that you take for granted what you are owed. Not being entitled makes every good thing in life a prize. You either achieved it or you were lucky, and those lead to feelings of pride or gratitude.

When you’re entitled, you don’t appreciate anything, and you’re frequently disappointed. Not a good combo. And when psychologists are evaluating if someone is a narcissist, guess what one of the four criteria is? Yeah, entitlement.

(To learn how mindfulness can make you happy, click here.)

Maybe you’re not worried or angry. Maybe you’re just overwhelmed by sadness about something. Well, I have a question for you…

“Must I Have This To Live A Happy Life?”

Plenty of people have a lot less than you and live a very happy life. If happiness was all about money then every single person in the developing world would be miserable. People who have lost a loved one, who have become handicapped, or heaven forbid, had a bad hair day, are all capable of living happy lives.

What do you truly need to live a happy life? (Hint: the longer your list, the more miserable you will be.)

As Marcus Aurelius said:

Very little is needed to make a happy life; it is all within yourself, in your way of thinking.
So next time you don’t get something you want and it makes you sad, ask yourself, “Must I have this to live a happy life?”

Yeah, yeah, forgive me — it’s another trick question. The answer is almost always “no.”

Maybe you didn’t get that promotion. And when you ask yourself the question, your first thought is “But my career is important to my happiness!”

Hey, I underlined the word “this” for a reason, pal.

Yes, your career is important. But is this promotion, right now, vital to the happiness of your life? No. Who knows what the future holds? And some of that is under your control. There are many ways to live a happy life and very rarely will this one thing make or break you.

(To learn the four rituals neuroscience says will make you happy, click here.)

Now when you’re consumed by negative emotions it can be very hard to make good decisions. Which means more bad stuff happens, which means more bad feelings. So how do you make smart choices when you feel awful? Just ask…

“Is This Who I Want To Be?”

News flash: there is no singular, concrete “you.” Neuroscientists have poked around at plenty of grey matter and there’s no spot in there that contains a stable “you.” And Buddhists were saying this over a thousand years ago.

Neuroscientist and Buddhism practitioner John Yates explains:

We often believe we should be in control, the masters of our own minds. But that belief only creates problems for your practice. It will lead you to try to willfully force the mind into submission. When that inevitably fails, you will tend to get discouraged and blame yourself. This can turn into a habit unless you realize there is no “self” in charge of the mind, and therefore nobody to blame.
Tons of things affect your decisions every day. Context, friends, and moods all affect what you do and who you are. This is a good thing, because it means you can change.

But it presents a challenge because it means you need to decide which person you will be today, Sybil. And this isn’t something you want to get wrong. What is the #1 regret people have on their deathbeds?

I wish I’d had the courage to live a life true to myself, not the life others expected of me.
Yow. So who should you decide to be? We can turn to modern science for this answer: Be you on your best day. So when making tough choices think about whether what you plan to do is aligned with the “you” you’re most proud of.

Merely thinking about your best possible self makes you happier:

Results generally supported these hypotheses, and suggested that the [Best Possible Self] exercise may be most beneficial for raising and maintaining positive mood.
And don’t worry about seeming inauthentic either. When you act like your best self, you end up showing people what you’re really like:

…positive self-presentation facilitates more accurate impressions, indicating that putting one’s best self forward helps reveal one’s true self.
(To learn the schedule very successful people follow every day, click here.)

Alright, this has all been very focused inside your head. How can you be emotionally strong when someone you’re dealing with is being emotionally weak or difficult? If someone else is anxious, angry, or sad, and it’s making your life rough, that can bring you down. How do you help both of you? Ask yourself…

“Have I Ever Felt That Way?”

Whatever they are going through, you’ve probably felt something similar. So be compassionate.

Both Buddhism and Stoicism believe in doing your best to reduce the suffering of others. Buddhism has the four divine abodes: loving-kindness, compassion, sympathetic joy, and equanimity. And on the Stoic side, good ol’ Marcus Aurelius said:

Be tolerant with others and strict with yourself.
Compassion sounds nice, but does it really produce results? Absolutely. And you get bigger benefits if you do it when you are least likely to want to — during an argument.

Via 100 Simple Secrets of Great Relationships:

People who maintain a compassionate spirit during disagreements with their partner, considering not just the virtue of their position but the virtue of their partner, have 34 percent fewer disagreements, and the disagreements last 59 percent less time. – Wu 2001
(To learn how to have more grit — from a Navy SEAL — click here.)

Okay, we’ve learned a lot. Let’s round it up and learn the most important part of being emotionally strong…

Sum Up

Here are the 5 questions from ancient wisdom that will make you emotionally strong:

  • “Is it useful?”: Most worrying isn’t. Make a decision to do something or to let it go.
  • “Does the world owe me this?”: No. Don’t be entitled. Have realistic expectations and you won’t get angry.
  • “Must I have this to live a happy life?”: Probably not. It takes little to make a happy life and there are many ways to get those things.
  • “Is this who I want to be?”: Act the way you do when you’re at your best.
  • “Have I ever felt that way?”: Respond to others’ problems with compassion and you’ll both have fewer problems.

The most important part of emotional strength is not calming your mind. It’s being resilient. It’s trying again after you’ve been shaken by negative feelings.

There are plenty of areas of your life where this is critical, but none is more important than your relationships — research shows 70% of your happiness comes from relationships.

You will be hurt. You will feel bad at times. That’s life. Sorry, there’s no avoiding it. So the question is: who is worth it? Who is most meaningful to you?

So when things are hard, have the emotional strength to still give to them and help them and care for them. You now have tools to weather the storm. Earlier I mentioned the biggest regrets that people had when they were dying. Know what #3 was?

I wish I’d had the courage to express my feelings.
So go first. Let someone know how much they mean to you. Who are we most likely to love? Research says it’s the people who first show us love.

Recently, I have been lucky enough to have this happen to me. And I can tell you nothing feels better.

Enough reading, time for doing. Right now, have the emotional strength to tell someone important how you feel, to forgive someone, to let someone back into your life, or to reconnect with someone you miss.

Don’t wait around for something negative to develop emotional strength. Flex some now and see how happy it can make you.

Please share this on Facebook or save it to Pocket. Thank you!

 

 

Thanks for reading!
Eric
PS: If a friend forwarded this to you, you can sign up to get the weekly email yourself here.

 

Stephan Guyenet: Why your brain makes you fat

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In this interview, which you can listen to or read,  neuroscientist Stephan Guyenet discusses various topics related to a big issue with a lot of people, how we get fat and what we can do about it, with Kris Kresser.

 

https://chriskresser.com/why-your-brain-makes-you-fat-with-stephan-guyenet/?utm_source=activecampaign&utm_medium=email&utm_term=rhr-why-your-brain&utm_content=&utm_campaign=blog-post

Susan Pierce Thompson: How to be happy, thin and free

the-3-huge-mistakes-report

This March, Susan’s first book, Bright Line Eating: The Science of Living Happy, Thin & Free, arrived in bookstores.

Here’s what she had to say:

Susan, in Bright Line Eating, you argue that the reason so many people struggle with their weight is that the human brain blocks weight loss. How so?

The human brain was designed to keep us stable in a right-sized body. But modern processed foods and the modern pace of life have hijacked various systems in the brain, and the result is that now, in the present-day environment, the brain does indeed block weight loss.

Here’s how: willpower is a finite resource in the brain. And it doesn’t just help us resist temptations or persevere in the face of challenges – it helps us do all kinds of things, like make decisions (e.g., checking email, going shopping), regulate our emotions (e.g., having kids, being in traffic), and regulate our task performance (e.g., working in Excel, giving a presentation).

After a brief period of time doing any of these things, if we start to think it might be a good time to get something to eat, we’re likely to fall into the Willpower Gap.

This is why so many of us order out for pizza or take-out on a Friday night after a long week, irrespective of how sincere we were when we pledged that this time we would stick with our diet until we lost all our excess weight.

In our modern society, the Willpower Gap is waiting for us, nearly always. Most plans of eating implicitly ask you to rely on your willpower to stick with the plan over the long term. The truth about your brain is that that will never work. You need a plan of eating that assumes you have no willpower at all (because, at any given moment, you may not), and works anyway.

To avoid relying on willpower, you suggest people adopt 4 “bright lines” into their eating habits. What are they?

Bright lines are clear, unambiguous boundaries that you don’t cross, no matter what–similar to how a smoker who wants to quit and get healthy throws up a bright line for cigarettes. The four bright lines I recommend are:

  1. No added sugar or artificial sweeteners
  2. No flour of any kind
  3. Eating only at meals–no snacking or grazing
  4. Bounding quantities of food, both to make sure you get enough vegetables, and to make sure you don’t eat too much of everything else.

What’s one thing everyone reading this can do right now to improve their chances of maintaining a healthy weight?

To really bridge the Willpower Gap, start writing down what you’re going to eat for the day in a little journal, ideally right after dinner the night before. Do it religiously until it becomes a habit. The next day, your job is to eat only and exactly that, no matter what. Make sure there’s no sugar or flour in your food plan for the day, and, ideally, stick with three meals a day, because three meals are much more automatizable than five or six.

Within a few weeks these habits will be automatic, and eating the right things, and not the wrong things, will start to be as easy as brushing your teeth.

 

(From original interview by Ron Friedman)

Planning a pregnancy: the importance of getting slim before you get started

newborn baby

In Europe the World Health Organisation estimate that more than 50% of men and women are overweight or obese and 23% of women are obese.

In a pregnant woman obesity raises her chances of gestational diabetes and pre-eclampsia. She is also more likely to get metabolic syndrome and type two diabetes later in life. The resulting children are more likely to come to harm in utero and at birth and also more likely to become fat children. They are then more likely to develop higher blood pressure and excess weight in early adulthood.

Despite the push to improve the outcome for the babies in utero, lifestyle changes and medical interventions have largely proved unsuccessful.

Women with a BMI over 25 find it more difficult to conceive in the first place and then are more likely to miscarry compared to their slimmer sisters. The miscarriage rate is 1.67. Congenital abnormalities become more common.

The placenta responds to maternal insulin levels. In normal weight women they become 40-50% less sensitive to insulin but this bounces back within days of delivery. Obese women show greater decreases in insulin sensitivity, this affects lipid and amino acid metabolism. African Americans and Southern Asians get these changes at lower body masses than Europeans.

Obese women are more likely to go into labour early. They also may need to be delivered early. They have a higher rate of failed trial of labour, caesarean sections and endometritis and have five times the risk of neonatal injury.

Anaesthetic complications are more common. The Royal College of Obstetrics and Gynaecology recommend that women with a BMI over 40 see an obstetric anaesthetist before going into labour. Epidural failure is more common. The woman may have lower blood pressure and respiratory problems and the baby may have more heart rate decelerations in labour.

Broad spectrum antibiotics are recommended for all caesarean sections. Despite this, overweight women get more post- operative infections. The wounds are also more likely to come apart.

Obese pregnant women are obviously at even more risk.

Babies of obese mothers are usually fatter at birth compared to other babies. Obese mums tend to put on more weight than average during the pregnancy and then find it even harder to lose weight after delivery.

Recent randomised controlled trial  have shown that interventions started after pregnancy have little or no effect. These include increasing the mum’s physical activity and cutting the dietary glycaemic load. These things reduced the weight gained in pregnancy a little but did not affect adverse pregnancy outcomes and the birth of fat babies. Thus there is now a bigger push to intervene before pregnancy.  

Currently between ten and twenty percent of obese women lose weight between pregnancies. This has been found to reduce weight gain in the next pregnancy and also the risk of pre-eclampsia.  Supervised intensive lifestyle interventions can be done, work and are safe, even in breast feeding mothers. Pre-pregnancy classes to get women fit for pregnancy would help improve the outcome for the babies of the future.  The metabolic environment, a mixture of inflammation, insulin resistance, lipotoxicity, and hyperinsulinemia,  can then be optimised prior to conception. After this, it is really too late.

 

Adapted from Obesity and Pregnancy. Patrick M Catalano and Kartik Shankar from Cleveland Ohio and Little Rock Arkansas Universities.  BMJ 18 February 2017 BMJ 2017;356;j1

Obesity raises the risk of cancer

cancer

Obesity is strongly associated with eleven different cancers.

These are: oesophageal, multiple myeloma, stomach, colon, rectum, biliary tract, pancreas, breast, endometrium, ovary and kidney.  For many cancers there seems to be a dose response.

This was found by Kyrgiou and colleagues by studying over 95 meta-analyses from various sources.

The BMJ reports, “The unavoidable conclusion is that preventing excess adult weight gain can reduce the risk of cancer. Furthermore, emerging evidence suggests that excess body fat in early life also has an adverse effect on the risk of cancer in adulthood. Clinicians, particularly those in primary care, can be a powerful force to lower the burden of obesity related cancers, as well as the many other chronic diseases linked to obesity such as diabetes, heart disease and stroke. The data are clear. The time for action is now.”

As a GP, I don’t really think that I am a “powerful force” that can turn the obesity epidemic round. It is amazing what faith the authors Yikyung Park and Graham Colditz have regarding our abilities.

 

Adapted from Adiposity and cancer at major anatomical sites BMJ 2017; 356:j477 and BMJ 2017;356:j908

Dame Sally Davies reports on the health of Baby Boomers: and it’s pretty shocking stuff

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The Chief Medical Officer of England has released a report into the health of Baby Boomers. This is the group of people born between 1945 and 1965. I’m one of them, maybe you are too.

We are living longer but are not really in better health. A huge burden of cardiovascular disease and cancers would be reduced if we looked after ourselves better by not smoking, eating better, keeping slim,  exercising, and drinking less.

Obesity and diabetes are increasing markedly through all classes of society. Obesity, particularly central obesity, is increasing. By waist size alone 80% of us are obese!

Liver cancer is now making an impact on deaths. 

Diseases that don’t kill but make you unfit to work and miserable include musculo-skeletal problems, visual and hearing loss. These are having a considerable effect.

Smoking is reducing but more than 6 out of ten smokers say that they have NEVER been advised to stop smoking by a doctor or nurse in their entire lives. Dame Sally thinks this is shocking. I think these smokers have shockingly bad memories.

Men are drinking less than 20 years ago but women are drinking more. The new guideline is less than 14 units a week for everyone.

One thing we are doing less of is physical activity and exercise. This is down from even just ten years ago with two thirds of Baby Boomers doing less than 30 minutes of exercise in the last month.

 

Here is a large chunk of the report:

Physical health

A key finding is that whilst life expectancy in 2013 increased compared with that of men and women in the same age group in 1990, overall morbidity remained unchanged. This means that we live longer but our health and well-being has not actually improved.

The data report substantially decreased death rates from each of the leading causes of disease in both male and female adults aged 50–69 years in 2013 compared with people who were in the same age group in 1990. These declines in mortality are success stories.

In particular, mortality rates from ischaemic heart disease (IHD) fell by over three- quarters in 50–70 year-olds during this time. Nevertheless, the fact that it still remains the leading cause of mortality in this age group is indicative of another issue; the leading risk factors for premature mortality in this group are IHD risk factors that are all modifiable, the top three being smoking, poor diet and high body mass index. The cancer types (oesophageal cancer in men, uterine cancer and liver cancer) that thwart the downward trend in premature mortality from cancer also have associations with modifiable risk factors such as alcohol and obesity.

In terms of morbidity, risk factors responsible for a remarkable 45% of disease burden in 50–69 year-olds in 2013 were again modifiable, with the leading three risks for both men and women being poor diet, tobacco consumption and high body mass index (BMI). The implication of this is huge: a large proportion of the disease burden in Baby Boomers is amenable to prevention.

Perhaps most striking is the case of diabetes. Morbidity from diabetes rose by 97% among men and 57% among women aged 50–69 years between 1990 and 2013. Although this definition includes both type 1 and type 2 diabetes, the attributable risk from factors including obesity, diet and low physical activity rose by 70%. There is a deprivation inequality in diabetes, as there is with all the leading causes of morbidity and indeed life expectancy. However, with diabetes the gap is decreasing, showing that this is an increasing problem regardless of social stratum. Interestingly, compared with tobacco consumption, which is strongly socially stratified, body mass index is now less socially stratified in terms of the size of the attributable burden of risk factors. These data suggest that it is extremely important that we strive to reduce inequalities in the health of Baby Boomers. In addition, weight and obesity must be addressed across the board.

Despite the fact that tobacco consumption in adults overall is decreasing, it remains an important risk factor in this group, remaining the leading risk factor for premature mortality and the second leading cause of total disease burden. Socioeconomic inequalities in tobacco consumption and related illnesses are well recognised and exemplified in this group. However, an additional inequality is the fact that the decline in premature mortality from lung cancer in women is less than half that in men.

Several issues highlighted in my previous surveillance reports hold true for Baby Boomers. My concerns, as Chief Medical Officer, about the increase in premature mortality in England due to liver disease in England (compared with mortality figures for our European counterparts) have been echoed by the trend in premature mortality from liver cancer in this age group. My calls for more robust systems for surveillance of high burden diseases, such as musculoskeletal disease, and sensory (visual and hearing) impairment, which impact more on quality of life and productivity than on premature mortality, are strengthened. Sensory impairment is the second highest cause of morbidity in this age group in men and the fifth in women. Yet needs are likely to be unmet, given the considerably lower prevalence of hearing aid use compared with the estimated prevalence of objective hearing loss. Musculoskeletal disease has again been highlighted as having a lack of high-quality routine information at a national level. However, we do know that the burden is high, demonstrated by the tripling in the rate of elective admissions for back pain and primary knee replacement in 50–70 year old adults between 1995/96 and 2013/14.

Datasets on oral health are also limited. While the improved oral health of Baby Boomers compared with that of their predecessors is a considerable triumph, it is important that we have sufficient data to inform the provision of services given that, counterintuitively, this success may mean that demand increases.

smoking

Annual Report of the Chief Medical Officer 2015, On the State of the Public’s Health, Baby Boomers: Fit for the Future

Chapter 1

Lifestyle factors

The authors of Chapter 5 analyse data concerning Baby Boomers generated from the Health Survey for England 2013 and the English Longitudinal Study of Ageing (ELSA, 2012/13), a wealth of information on adults over 50 years of age. They analyse key factors affecting health such as smoking, alcohol, diet, physical activity and obesity, all of which are modifiable.

Baby Boomers had lower rates of smoking than those of the same age 20 years previously. The extent of the difference between the rates increases with age within the cohort. This is despite data from the physical health chapter which identify tobacco consumption as a leading cause of both mortality and morbidity in Baby Boomers. I find it shocking that, by this stage in their lives, in current and ex-smokers, 66% of baby boomer men and 71% of baby boomer women have never been recommended to stop smoking by a doctor or nurse. There is an unquestionable need for adequate support for smokers trying to quit and this questions whether services are targeting and reaching those who require them. Continued provision of Stop Smoking services is vital. A sustained decrease in the prevalence of smoking risks underestimating the needs of the baby boomer population for these services. They have lived through the height of the tobacco era and continue to experience substantial ill-effects from it. Locally appropriate services are also essential to reduce the resounding socio-economic inequalities and the geographical variation evident in smoking prevalence among Baby Boomers.

The UK Chief Medical Officers published new guidelines on low risk drinking in August 2016. For both men and women the guideline is that to keep health risks from alcohol to a low level it is safest not to drink regularly more than 14 units a week and that for those who drink as much as 14 units per week it is best to spread this evenly over three days or more, and that several drink-free days in the week aid cutting intake. Although in terms of units per week, baby boomer men were drinking less than those in the same age group 20 years earlier, the proportion of men now drinking on five days a week increased with age, with the highest rate of 30% in 65–69 year-olds. Whilst still within the guidance for low risk drinking it is of concern to me that, on average, baby boomer women reported drinking more than women of the same age 20 years previously, with a maximum difference of 3 units per week (from, on average, 4.5 units per week in 1993 to 7.5 units in 2012-13) in women aged 60-64 years

Given the increase in obesity rates seen in recent years, it is of little surprise that overweight and obesity levels were significantly increased in Baby Boomers compared with adults of the same age 20 years earlier. The authors found that nearly half of baby boomer men and over a third of baby boomer women were overweight. Around a startling 75% of men and 80% of women were classified as centrally obese if raised waist circumference (defined as 102cm in men and 88cm in women), a risk factor for diabetes, was used instead of BMI (with 77% of men and 83% of women being classified as obese by 65–69 years of age using this criterion). These statistics are staggering. If these adults are to reduce their current risk and maintain their health through older age, it is critical that this is addressed. I have previously expressed my concern regarding the ‘normalisation’ of overweight and obesity, referring to the increasing difficulty in discerning what is normal from abnormal due to the fact that being either above a healthy weight or obese is now so commonplace. The fact that 1 in five men and nearly half of women classified as having a ‘normal’ BMI were in fact found to be centrally obese is extremely concerning, and underlines the importance of promoting awareness of metabolic risk factors such as increased waist circumference, in addition to BMI.

The UK Chief Medical Officers’ guidelines on physical activity recommend that adults participate in 150 minutes of moderate intensity, aerobic, physical activity every week . Physical activity was found to be low among Baby Boomers. Not only did the authors find that people in their 50s were less active than those of the same age 10 years earlier, they also found that two-thirds of all Baby Boomers in their sample had undertaken no physical activity lasting more than 30 minutes in the past month. Significant geographical, socio-economic and ethnic inequalities exist in physical activity. I was surprised, for instance, to find that rates of inactivity were as high as 80% in Gateshead and Stoke on Trent. Physical activity has benefits in terms of cardiovascular health, mobility, weight management and even cognition. Clearly, this age group could benefit greatly from optimising physical activity levels to maximise their health both currently and in impending ‘older age’.

Lifestyle of older adults in England

Physical activity and weight

1 in 3 OF THOSE AGED 50-70 ARE OBESE according to BMI and this is much worse if you rely on waist circumference.

 

18% women and 19% of men smoke

65-70% who are smokers/ex smokers have never been asked to stop smoking by a doctor or nurse (so they say!)

 

65.6%    of Baby Boomers have not engaged in any moderate physical activity lasting 30 minutes or longer in the  past month

Amongst 50-60 year olds: Men are drinking  approx. 4-5 units a week less than 20 years earlier Women are drinking approx. 2 units a week more than 20 years earlier

 

Weight plateaus are a normal, but frustrating, feature of your weight loss journey

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 Here are some words of wisdom and encouragement from a health care professional who knows how discouraging weight loss plateaus can be. Don’t let weight stabilisation lead you to jack in your efforts.
When Losing Weight, Warn ‘em!

Diabetes in Control November 8th 2016

I work in obesity medicine. As many of us know, losing weight isn’t the problem for most, but weight regain is.

As the saying goes for many, you can’t be rich enough or thin enough. Many of our patients come in with unrealistic goals regarding their weight loss, and don’t give themselves enough credit for the weight they have lost. Many, for many reasons, regain.
Woman, 58 years of age, class II obesity, prediabetes (A1C 6.0%), HO depression, on antidepressants, weight of 188, BMI 38. Started on metformin and lower carb meal plan.
Warned her early on it’s not just about losing weight, but what’s important is keeping it off. We need plans for both.
Her treatment plan does not end when she loses weight.  Over 6 months she lost 22 pounds. This is a 12% weight loss. BMI 33.5 now.  No further weight loss since the 6-month period, but no weight gain.
Patient frustrated. She has upped her exercise. No longer wants to continue metformin. Encouraged her to continue her meal plan, metformin and bump up her exercise plan. Praised her for her weight loss and not regaining.  And, reminded her this is what we discussed from the start. She remembered and said she’ll stay with the plan.
Lessons Learned:
  • Keeping weight off is a different stage of the weight loss journey.
  • Reminder that losing 3-5% total body weight can improve health outcomes.
  • 5-7% weight loss was shown in the DPP to prevent or delay type 2 diabetes.
  • From the beginning, let patients know there are stages to losing weight. First is to lose, then it’s to keep off the weight lost. Make a plan for both.
  • Regarding weight loss, put more emphasis on the food side.
  • Regarding weight maintenance, put more emphasis on exercise.
  • Remind patient of discussion and encourage patient to embrace the weight loss they have been able to achieve and keep off.

Anonymous