Often people will ask me where we get our definition of keto-adaptation as being consistent blood glucose below 85 and morning ketones between.5 and 3. It’s an obvious logical step in understanding how the body adapts. Ketones and glucose compete for fuel. You can’t get into a zero glucose state–there are brain cells, for example, that can only operate on glucose, although the amount of glucose the brain needs is minimal and doesn’t need to come from dietary sources. The brain can use multiple substrates (fuel sources) and becomes more efficient when it does so. The brain that operates only on glucose is an inefficient brain. The problem is the Standard American Diet trains brains to run on glucose only–so much so that it becomes glucose dependent and its use of other available substrates becomes minimal. This leads to premature aging, neurodegenerative disease, and flat out grey matter shrinkage. It also provides epigenetic therapy reducing the expression and/or effect of genes that lead one toward cancer, CVD, and auto-immune disorders.
The goal is to get our glucose dependent brains to be operating on multiple other substrates, which it really is designed to do. Astrocytes, for example, make their own ketones in the brain, it wants to be using ketones, even if we’ve beaten it into submission with years of glucose flooding. All we need to do is provide the brain with enough ketones (and pryuvate and lactate–but that’s another post) to let it begin to operate optimally.
But how do we do that? Well, people started testing ketones. If I’m making ketones then I must be using them, right? Well. Hold on there. We know that high amounts of circulating ketones and even pure fatty acids can reach the mitochondria of the muscle tissue through capillaries providing an energy source.
It’s only in considering just HOW the ketones reach the brain that the circulating blood glucose becomes not just relevant to keto-adaptation but crucial to it.
The brain is surrounded by something called the BBB–the blood brain barrier. The BBB has selective permeability that varies in different metabolic states. Those who have hung around KetoChix a bit understand that everything in biochemistry works in ratios (that’s why we figure out our food macros not in absolute calories but in ratios of fat:protein + carb) and substrates in the body have the tendency to act like a clutch and gas pedal. In this case you can think of glucose as clutch and ketones as the gas. Because the ketones can only GET to the brain if the circulating plasma glucose is low. It works in an inversely proportional ratio.
The important thing to remember is that glucose and ketones have the gas and clutch relationship. What people started doing when measuring ketones was to verify that you are eating sufficient fat and keeping carbs low enough that you are actually making them. That’s only the first step. The idea is that you are using them, preferentially. The lower your blood glucose, the more your tissues—all of your tissues not just brain tissue–are using ketones as their PREFERRED fuel. Since large population studies correlate disease states with fasting blood glucose of over 85, we can guess where that gas and clutch rhythm reaches its maximal efficiency.
Some more studies to read if you want background and like to connect dots:
Many of the KetoChix are in a process of food elimination. And you may wonder—but I do dairy/nuts/keto desserts/whey powder/eggs is that okay? Anything you do on keto is “okay” as long as you are getting fasting ketones above .5 and BG below 85. Don’t think in terms of evil foods. The original studies on ketogenic diet included foods like white bread and bran biscuits. No food is “not keto” as long as your ketones and BG are in the happy zone. However, some foods can cause unintended secondary effects. White bread for example in small amounts may be manageable if attenuated by fat and protein. But before you go running out to Panera–the earliest ketogenic patients were small children which means a) more glucose tolerance b) they were being tightly controlled. For most of us who are older and more metabolically damaged with age-related insulin resistance, the ill effects of white bread would not be good for BG control. Furthermore, the glycemic index and inflammatory reaction caused by white bread may make us irritable, tired, and more hungry, making trying to eat within our macros a more challenging and potentially miserable experience. However any question you have always ends with:What’s your average fasting BG and what is happening to your lean mass? That is your ultimate arbiter.
If after eating within your macros for 90 days your BG isn’t low and steady, anything is fair game and a potential suspect. Even”keto-friendly” foods–according to popular web wisdom–like brassicas and night shades or nuts and nut flours–are potential suspects because they have compounds that you can be sensitive to. But take everything one at a time. First, begin getting your macros in a good shape. Things don’t happen immediately. Master that and do it steady for at least 90 days. Then, re-evaluate. Are your BG numbers going down? Are you maintaining or gaining lean mass?
There are different phases and methods in this diet–and as a patient of ours you would introduce this diet gradually testing things as you go. Here I teach you roughly how to do it on your own. The important thing to remember is you must give every new habit, every change you implement TIME to work. Go slow. Don’t take on too many changes at once. (Phew, you are thinking. I can keep my heavy whipping cream!)
And you can comfort yourself: getting down to brass tacks and doing food elimination doesn’t always become necessary. Some people without a large degree of metabolic damage and already exhibiting a healthy wild genotype do quite well in the earliest phases of the diet and have tremendous response to minimal changes. They adapt easily and they don’t have to put a lot of effort into staying in the health zone. But for a lot of people it is really hard. Let me emphasize WEIGHT LOSS (or lack of it) isn’t the biggest index of whether or not you are in the health zone either. It’s your BG, you albumin, your A1C, your RBC and WBC, and your ROS. So far, only the BG is something you can manage from home. But you can guess at the others based on that. You could be losing weight but still be in trouble. And not losing and doing well. You aren’t going to necessarily know without testing. (Not to mention that the scale goes UP when your are putting on lean mass.)
So, then, what if you health index isn’t doing well? What if your BG is chronically elevated or bouncing all around? What if that lasts 90s days or more? So many come into this with an attitude of PRY MY CHEESE/HWC/COFFEE/nuts from my cold dead hands!! They will argue with me that whatever they are attached to is NOT affecting their BG. Clearly, however, if you aren’t getting good numbers back it IS. And the thing is MILD elevations have a tendency to get worse over time.
Keep in mind–elimination is always a temporary measure to manage your health index. It doesn’t necessarily mean that you can NEVER EAT THAT FOOD AGAIN. Don’t fight that battle with yourself.
The other thing about things like dairy and keto deserts etc. is they are potential ABUSE FOODS. So many of us have used food as a drug—and that is natural and normal. Food has a nutriceutical quality and therefore it has mind and mood altering effects for good reasons. But when we are hiding from change in our lives insisting on staying in stuck, unhealthy patterns we can use that mind altering and mood altering effect to elevate our mood and avoid the pain that would motivate us to change if we confronted it. When we use those foods that way we almost always over consume them. And “over” consumption is relative to you. A whole wheel of brie seems like a lot–but is 2 oz? What about 3ozs? It’s subjective.
For me, I am being forced to confront that I overschedule. Almost every bad choice or less than optimal situation occurs from being overscheduled. Dairy was an easy way for me to grab food and go–and I am paying the price for that in eliminating it. Rather than slow down I am skipping meals to bad effect. Now I have to look at that. It’s like peeling an onion. Get rid of my grab and go cheese addiction–and I suddenly have to look at the fact that I schedule more than is possible to do AND have good healthy habits and hygiene. It’s how it all works.
It is not unusual for big life changes to occur when you are in the process of elimination because removing crutches–things we over-rely on and feel irrationally attached to–makes us confront pain that makes us change. Change is good. Growth is good. You are becoming your better (and better) self.
This was a recent talk given by our hero Dr. Wahls in Calgary.
Tagging off my recent post on why we oppose Zero Carb–at about 21:00 Dr. Wahls talks about Dr. Bowman’s research, which inspired her to track, test, and target 31 different micronutrients in her quest to provide optimal mitochondrial nutrition.
Dr. Bowman’s research was very similar to Dr. Perlmutter’s in that he tracked nutrient levels and the size of the brain. The size of your brain isn’t always apparent (although it may show up in bizarre behavioral and attitudinal eccentricities and poor cognitive performance) but it can be correlated to your nutritional status in significant ways.
Dr. Wahls emphasis on low glycemic vegetables is because of the importance of these nutrients. In order for your ketogenic diet to be optimal you must include these vegetables in your diet. Crucifers and sulfur, leafy greens, and richly colored vegetables and berries. You also should be eating wild caught fish and organ meats and focusing on grass fed meats in order to get the right amount of nutrients.
However, some things may come up in an attempt to fulfill this diet. Some people have food sensitivities, allergies, gastro-intestinal issues, or insulin resistance that makes some vegetables difficult. They will either cause allergy or disease flares, intestinal issues, and higher blood glucose. (For example I am limited at the moment to some sulfur in the form of mushrooms, onions, and garlic, 1-2 cups of leafy greens–if that–and avocados or else I may have serious gastrointestinal distress, disease activity, and higher blood glucose.) The goal is to repair and heal the body so eventually the body can tolerate these nutritionally dense foods and it does happen. As you blood glucose becomes more stable you become less reactive.
But here’s a reason NOT to cut those foods out: the scale moves quicker if you do. Ill-informed and not a good choice.
So what about in the meantime? If you are among the gastro-intestinal/allergy/autoimmune/insulin resistant patients who have sensitivity to these vegetables?
You might at this time consider supplementation.
Here is what I am doing currently–we do not necessarily have a formal recommendation for supplementation at this time, but I am experimenting on myself and using my own blood work to find the happy medium for me. You should consult with your doctor on your own recommendations as mine may not be the same as yours. For example, I have chronically low vitamin D, low CO2, chronically high WBC, and MTHFR so my levels are set to that. Particularly the vitamin D supplementation should be worked out with your primary care provider:
-a vegetable and fruit extract multivitamin (an insurance policy against all the nutrient dense vegetables and fruits I am not having).
-200 mg of CoEnzyme Q10
-5000 IU of Vitamin D3
-methyl B12 1000 mcg
-methyl folate 1000 mcg
-calcium citrate 250 mg
-algae capsules
Food is always the best source of any nutrient–supplementation is not entirely benign and it can also have its own unintended secondary effects so always approach supplementation with caution and discuss with your primary care provider.
When you are testing KetoChix style, it is important to know that many factors go into your blood glucose. It’s easy for some people to say “don’t worry about it,” because for some it seems stressful and anxiety producing. For others, it forces them to confront yet another lifestyle change when they feel they’ve already given up so much to achieve what they think is an optimal ketogenic diet. Still others think they’ve already learned all they need to know, and won’t find anything useful in testing. And, certainly, if your blood glucose readings and their variability is stressing you out, you may consider not doing it. Like those who fret about the scale, it can be counterproductive and you shouldn’t read TOO MUCH into it. Keep Calm and Keto On is a saying for a reason. The KetoStix trend that inspired the ironic title of this blog and our group sent people into tizzies peeing on sticks, when it turned out that information was of very limited use. KetoChix know better. We observe over longer periods of time and take our data lightly. (Which doesn’t mean not taking it seriously. Another post, peeps. Another post.)
So Not Testing is an option, though it is obviously not the approach we support and promote. There are many different personality types in this world and not all of them can find help in all approaches to nutrition and health. Only certain kinds of people are capable of taking a rational approach to their own health, understanding that averages are more important than single readings, and accepting a significant margin of error in meters that iron out in the averages but not in a single reading. Others would do better under the scrupulous care of a professional who understands the ketogenic approach. You know yourself. It’s no crime to admit that it’s all just too technical. And what may seem too technical now may not seem so later. You can crock pot it, like your awesome sauce known as bone broth. Learn more about the diet and your body and come back to it when you are ready. Nothing wrong with that.
But if you have jumped into the KetoChix method of testing, observing, and tinkering with your own health, it’s also important to note that even though the popular statement on the boards is that keto-adaptation takes “3 weeks” this was based mostly on studies on elite athletes who by definition are exquisitely insulin sensitive due to high lean body mass. Most of us are the opposite of insulin sensitive. Most of us have long-term metabolic damage that will not be overcome with just three weeks of lipid therapy. Long term, sustained, positive nutritional changes that embrace healthy fats (ratio of omega 3 to omega 6 of at least 1:1), moderate protein, and low carbohydrates coming from nutrient dense vegetables and limited fruits will have a gently sloping effect on blood glucose over a long period of time with many little ups and downs along the way due to many factors.
But what if you AREN’T being neurotic? What if no matter what you do, your fasting BG stays in an elevated place? Despite some bloggers (a few of them quite impressive, otherwise, too) suggesting that it’s “normal” and nothing concerning, this is not the case. But determining what the issue is can be a bit of puzzle since there are so many factors. Here are some of the top ones. Don’t jump to conclusions. KetoChix observe, record, and tinker. Think: it might be one of these. Just watch and observe.
1) Nutrition
This is the obvious to any KetoChick. The macros in wrong amounts will make blood sugar go up. Fat in general is blood glucose neutral (and may even lower BG) but the wrong kind of fats (omega 6 for example) can make your BG go up gradually over an extended period of time. Most research on fats and metabolic syndrome in the past were based on nutritional design that always included saturated fat in the presence of carbohydrates. Be particularly cautious about nuts and seeds and their oils and poor quality fats in commercial dairy and meats. Medium chain fatty acids (the most famous being coconut oil) will likely lower your BG and is at least neutral. Carbohydrates obviously will spike blood glucose but excess protein can also cause a long term rise. The effect of protein is more or less in the individual because of sensitivity. Women, for example, are much more sensitive to protein than men. Those further along the insulin resistance spectrum will also have a more obvious example. But even those with no apparent response may see their blood sugar creeping up over time. As we become more insulin sensitive our protein needs will decline as we can focus the use of protein on cellular repair and rely on ketones to fuel the brain and fatty acids to fuel the muscles. Caffeine and alcohol can make blood glucose go up or down, depending. Jury is still out. But you always have to look at these two things that most of us love. Finally, there may be foods that you are sensitive to that don’t generally create blood glucose issues for the population but MAY for you. The most common offenders are dairy, eggs, nuts, seeds, night shades and mold growing substances like coffee and cocoa. The reason why is…
2) Environment
Environmental allergies to mold, dust, pollen, etc. can raise your blood glucose from chronic inflammation as can toxins and poor methylation, both subjects that deserve their own posts.
3) Sleep
One of the most common problems is sleep. Poor sleep or sleep disruption (which you may or may not be aware of) will raise your blood glucose. Overnight arrhythmias, circadian disruption from caffeine or nicotine, and low c02 or 02 levels can raise your cortisol and prevent your organs (namely the pancreas and liver) from going into a more restful mode.
4) Hormones
Your natural hormones can cause slight elevations in blood glucose so you may see after you observe over a period of time that your menstrual cycle may cause gentle rise and fall. Hormone replacement therapy OF ANY TYPE (I don’t care if it’s “bioidentical” and therefore “natural”) can raise BG. Progesterone in particular will do so because the natural mechanism of pregnancy is to raise your blood glucose. Women are more prone to weight gain BECAUSE their hormones exist to protect a pregnancy. So if you take those female hormones you may expect weight gain, water retention, and sometimes, higher blood glucose. You have to do a cost-benefit analysis with your physician on that one. Our personal opinion is that hormones are over-used in general, but your doctor knows your particular issues.
5) Exercise
Exercise can make BG go up or down. Light exercise tends to make BG go down, heavy exercise tends to make it go up. Whether or not these effects are sustained over time is debatable. The general opinion is that light regular exercise and light resistance training will have a sustained BG lowering effect. But these terms are relative to YOU. A walk around the block could be highly stressful for someone with asthma or joint issues. Sometimes, you have to sustain a temporary rise in order to get a longer term drop. It’s just important to know that if you do some intense exercise and then test your BG and see it is over 100 that can be a factor. This is why the most important readings are ones that happen after fasting, ie, a good night’s sleep.
6) Stress, illness, and injury
Acute stress, illness, and injury can cause a temporary elevation from inflammation. If we have a patient with good macros and everything else is accounted for we will run a cmp and a cbc with diff. to look for signs of infection, frequently an impending virus or an asymptomatic uti infection.
Which brings us to the topic du jour: chronic inflammation from metabolic disorders. Please look here soon for a post on the differences between acute and chronic inflammation.
In which I explain that ketoadpation needs more specific, clinical definition and I define it as having steady fasting blood glucose under 85 and an A1C of under 5.
Have you noticed that all the cultural niches in cyberspace have their own language? Their own abbreviations, their own memes, their own repetitive ad nauseam arguments. Paleo/keto-nutrition is no different. When you start hanging around “Keto World” on the internet, you see the word “keto-adapted” a lot. When people are talking about adaptation, they aren’t always sure what they mean. For some people it is just a time period. After eating low carb and making ketones for about four weeks…you’re adapted. For others, it means something slightly more specific. Others seem to use it as a value system, “Hey Bro, you might not get the same results. I’m highly adapted.”
I will tell you what I mean when I say keto-adapted. I mean fasting blood glucose of <85, an A1C under 5, and blood ketones between .5 and 6. It’s in the numbers, baby. Have I mentioned I love data? The reason I define it this way is simple and can be broken into two parts:
1) If nutritional ketosis doesn’t result in numbers like this, there isn’t really an advantage to it from a long term health perspective.
2) By definition if you are generating enough glucose in the liver to raise your BG you are not fully keto-adapted, that is to say, you have not completely switched to being a ketone burner, preferentially. You are, in fact, still alternating between ketosis and glycolysis. It isn’t adapted/not adapted. There is a range and you can measure that range by how low the average circulating blood glucose is.
I’m going to explain this in a bit, but let’s get to the bottom of where the term comes from. The term keto-adapted has been used in the scientific literature since around 1977, and perhaps earlier, but language is a living thing and its meaning changes with use. More recently, the use of the term “keto-adapted” comes from the fact that when low carb diets first began getting tested they came out poorly in several categories. The defenders of the dietary approach knew, from practice, that it takes a period of time for the body to get used to using fats optimally. Soon, people were cautioning that to test the effects of low carb diets, the subjects need to go through a period of adaptation before you can effectively evaluate the benefits (or the liabilities) of the nutritional approach. It’s a qualifying term. Because everyone knows that if you give an athlete a low carb diet, initially they “bonk,” or lose their performance edge. The idea is that after a period of adaptation, their performance comes back up to and even outshines its former glory.
At a biochemical level, this comes in the form of more cellular mitochondria, working at higher levels of efficiency. This is the reason that those interested in ketogenic diets and health (like the awe-inspiring Terry Wahls) are finding such intriguing effects from using ketogenic diets to treat diseases as wide-ranging as epilepsy, cancer, Alzheimer’s disease, and autoimmune disorders, like MS. All these diseases of metabolism are mitochondrial diseases. Greater mitochondrial function, less disease. While all the mechanisms at work in the therapeutic effects of the ketogenic diet are not fully understood, certainly mitochondrial biogenesis is one the top suspects.
It seems like a leap to some, but to me it is clear. If keto-adaptation doesn’t include greater mitochondrial biogenesis it is meaningless. Since the popular books on the subject are directed at a lay audience who aren’t likely to do more than pee on a stick or prick their finger as a measure of adaptation–simply producing blood ketones (not urine or breath–but that’s another post) is enough and they use the studies done on athletes to conclude that “keto-adaptation” is completed by around 3 weeks.
This causes people to presume, however, that the maximal effects of adapting just stop there. They clearly do not as therapeutically Dr. Wahls has recorded continued improvement and health rebound up to 3 years. You need time to grow better, stronger mitochondria. You need time to replace inflammatory, insulin-resistant tissue with anti-inflammatory insulin-sensitive tissue. The idea that it can be done in a few weeks is fairly absurd. Further, through studies on disease response we can learn that there are adaptations that are stronger and adaptations that are weaker. Dr. Seyfried, for example has found that blood glucose beween 55 mg/dL and 65 mg/dL, and ketone levels between 3 mmol and 5 mmol provide maximal therapeutic benefit for tumors. When you move out of that range it loses its therapeutic effect. One might well say, well, I don’t have cancer. Except that misses the point: if the therapeutic mechanism is derived from “transitioning metabolism from glucose to ketone utilization for energy” as it was discovered here, it means that, metabolically there is a RANGE of adaptation because the person who has a fasting BG of 75 and ketones of 2.6, is certainly in ketosis. There is simply another LEVEL to that process of adaptation, one that apparently brings well-nigh miraculous therapeutic results in certain cases.
Not to mention that what is therapeutic is usually preventative. Vitamin C cures scurvy. It doesn’t follow that we should only take vitamin C to prevent scurvy. To say, I don’t need to worry about BG and A1C because I don’t have diabetes/cancer/epilepsy, is like saying, I don’t need vitamin C, I don’t have scurvy.
And here it is–scurvy is a deficiency. One might very well say that metabolic disorders like the ones here are diseases of dietary deficiency that lower mitochondrial function and decrease methylation over time. The ketogenic diet is the vitamin C. You don’t have to wait for damage to be done in order to maximally prevent it.
KETOCHIX 