Category Archives: Ketogenic Mediterranean Diet

Recipe: Apple, Pecan, Blueberry Lunch Bowl

paleobetic diet, diabetic diet, low-carb diet

So simple even a redneck can make it (I is a redneck)

Since I provide you with nutritional analysis below, you can easily work this meal into the Advanced Mediterranean DietLow-Carb Mediterranean Diet, or KMD: Ketogenic Mediterranean Diet.

Ingredients:

2.5 oz (70 g) apple, diced (“red delicious” variety works well) (this is half a medium-sized apple)

2.5 oz (70 g) pecans, crumbled into small pieces

2.5 oz (70 g) raw blueberries

Instructions:

Mix all together in a bowl, then enjoy. I know a lotta you bros will just eat all the components individually—but try the mix once for new flavors.

Servings: 1

Advanced Mediterranean Diet boxes: 1.5 fruit, 2 fat

Nutritional Analysis:

76% fat

20% carb

4% protein

570 calories

30 g carbohydrate

10 g fiber

20 g digestible carb

1.4 mg sodium

421 mg potassium

Prominent features: Quick and easy. Rich in copper, manganese, and thiamine. Inadequate protein to get you through the day, but you’ll make up for it at breakfast or dinner.

Mediterranean Diet Helps With Maintenance of Weight Loss After Ketogenic Diet

Italian seaside tangentially related to this post

Italian seaside tangentially related to this post

Investigators affiliated with universities in Italy and Greece wondered about the effect on obesity of two ketogenic “Mediterranean” diet spells interspersed with a traditional Mediterranean diet over the course of one year. They found significant weight loss, and perhaps more importantly, no regain of lost weight over the year, on average.

This scientific study is right up my alley. I was excited when I found it. Less excited after I read it.

The Set-Up

This was a retrospective review of medical records of patients of a private nutritional service in three fitness and weight control centers in Italy between 2006 and 2010. It’s unclear whether patients were paying for fitness/weight loss services. 327 patient records were examined. Of these, 89 obese participants met the inclusion and exclusion criteria and started the program; 68 completed it and were the ones analyzed. (That’s not at all a bad drop-out rate for a year-long study.)  The completers were 59 males and 12 females (I know, the numbers don’t add up, but that’s what they reported). Ages were between 25 and 65. Average weight was 101 kg (222 lb), average BMI 35.8, average age 49. All were Caucasian. No diabetics.

Here’s the program:

  1. 20 days of a very-low-carb ketogenic diet, then
  2. 20 days of a low-carbohydrate non-ketogenic diet for stabilization, then
  3. 4 months of a normal caloric Mediterranean diet, then
  4. repeat #1 and #2, then
  5. 6 months of a normal caloric Mediterranean diet

In the ketogenic phases, which the authors referred to as KEMEPHY, participants followed a commercially available protocol called TISANOREICA. KEMEPHY is combination of four herbal extracts that is ill-defined (at least in this article), with the idea of ameliorating weakness and tiredness during ketosis. The investigators called this a ketogenic Mediterranean diet, although I saw little “Mediterranean” about it. They ate “beef & veal, poultry, fish, raw and cooked green vegetables without restriction, cold cuts (dried beef, carpaccio and cured ham), eggs and seasoned cheese (e.g., parmesan).” Coffee and tea were allowed. Items to avoid included alcohol, bread, pasta, rice, milk, and yogurt. “In addition to facilitate the adhesion to the nutritional regime, each subject was given a variety of specialty meals constituted principally of protein and fibers. “These meals (TISANOREICA) that are composed of a protein blend obtained from soya, peas, oats (equivalent to 18 g/portion) and virtually zero carbohydrate (but that mimic their taste) were included in the standard ration.” They took a multivitamin every morning. Prescribed carbohydrate was about 30 grams a day, with macronutrient distribution of 12% carb, 36 or 41% protein, and 51 0r 52% fat. It appears that prescribed daily calories averaged 976 (but how can that be prescribed when some food items are “unrestricted”?).

I found little explanation of period #2 mentioned above, the low-carb non-ketogenic diet. Prescribed macronutrients were 25 or 33% carb, 27 0r 31% protein, 41 or 44% fat, and about 91 g carbohydrate. Prescribed daily calories appear to have averaged 1111.

After the first and second active weight loss ketogenic phases, participants ate what sounds like a traditional Mediterranean diet. Average prescribed macronutrient distribution was 57% carbohydrate, 15 % protein, and 27% fat. Wine was allowed. It looks like 1800 calories a day were recommended.

Food consumption was measured via analysis of 3-day diaries, but you have to guess how often that was done because the authors don’t say. The results of the diary analyses are not reported.

What Did They Find?

Most of the weight loss occurred during the two ketogenic phases. Average weight loss in the first ketogenic period was 7.4 kg (16 lb), and another 5.2 kg (11 lb) in the second ketogenic period. Overall average weight loss for the entire year was 16.1 kg (35 lb).

Average systolic blood pressure over the year dropped a statistically significant 8 units over the year, from 125 to 116 mmHg.

Over the 12 months, they found stable and statistically significant drops in total cholesterol, LDL cholesterol (“bad cholesterol”), triglycerides, and blood sugar levels. No change in HDL cholesterol (“good cholesterol”).

Liver and kidney function tests didn’t change.

The authors didn’t give explanations for the drop-outs.

Although the group on average didn’t regain lost weight, eight participants regained most of it. The investigators write that “…the post dietary analysis showed that they were not compliant with nutritional guidelines given for the Mediterranean diet period. These subjects returned tho their previous nutrition habits (“junk” food, high glycaemic index, etc.) with a mean “real” daily intake of 2470 Kcal rather than the prescribed 1800 Kcal.”

Comments

A key take-home point for me is that the traditional Mediterranean diet prevented the weight regain that we see with many, if not most, successful diets.

However, most formulas for calculating steady state caloric requirements would suggest these guys would burn more than the 1800 daily calories recommended to them during the “normal calorie” months. How hard did the dieters work to keep calories around 1800? We can only speculate.

Although the researchers describe the long periods of traditional Mediterranean diet as “normal caloric,” they don’t say how that calorie level was determined  and achieved in the real world. Trust me, you can get fat eating the Mediterranean diet if you eat too much.

I’ll be the first to admit a variety of weight loss diets work, at least short-term. The problem is that people go back to their old ways of eating regain much of the lost weight, typically starting six months after starting the program. It was smart for the investigators to place that second ketogenic phase just before the typical regain would have started!

There are so few women in this study that it would be impossible to generalize results to women. Why so few? Furthermore, weight loss and other results weren’t broken down for each sex.

I suspect the results of this study will be used for marketing KEMEPHY and TISANOREICA. For all I know, that’s why the study was done. We’re trusting the investigators to have done a fair job choosing which patient charts to analyze retrospectively. They could have cherry-picked only the good ones. Some of the funding was from universities, some was from Gianluca Mech SpA (what’s that?).

How much of the success of this protocol is due to the herbal extracts and TISANOREICA, I have no idea.

The authors made no mention of the fact the average fasting glucose at baseline was 103 mg/dl (5.7 mmol/l). That’s elevated into the prediabetic range. So probably half of these folks had prediabetes. After the one-year program, average fasting glucose was normal at 95 mg/dl (5.3 mmol/l).

The improved lipids, blood sugars, and lower blood pressure may have simply reflected successful weight loss and therefore could have been achieved  by a variety of diets.

The authors attribute their success to the weight-losing metabolic effects of the ketogenic diet (particularly the relatively high protein content), combined with the traditional Mediterranean diet preventing weight regain.

The authors write:

The Mediterranean diet is associated with a longer life span, lower rates of coronary heart disease, hypercholesterolemia, hypertension, diabetes and obesity. But it is difficult to isolate the “healthy” constituents of the Mediterranean diet, since it is not a single entity and varies between regions and countries. All things considered there is no “one size fits all” dietary recommendation and for this reason we have tried to merge the benefits of these two approaches: the long term “all-life” Mediterranean diet coupled with brief periods of a metabolism enhancing ketogenic diet.

I’ve attempted a similar merger with my Low-Carb Mediterranean Diet. Click here for an outline. Another stab at it was the Spanish Ketogenic Mediterranean Diet. And here’s my version of a Ketogenic Mediterranean Diet.

Steve Parker, M.D.

Reference: Paoli, Antonio, et al. Long Term Successful Weight Loss with a Combination Biphasic Ketogenic Mediterranean Diet and Mediterranean Diet Maintenance Protocol. Nutrients, 5 (2013): 5205-5217. doi: 10.3390/nu5125205

Ketogenic Diet Overview

We’re starting to see a resurgence of interest in ketogenic diets for weight loss and management, at least in the United States. Also called “very-low-carb diets,” ketogenic diets have been around for over a hundred years. A few writers in the vanguard recently are Jimmy Moore, Dr. Peter Attia, and Dr. Georgia Ede. Before them, Dr. Robert Atkins was a modern pioneer with his famous Atkins Diet and its Induction Phase.

What is a Ketogenic Diet?

There are many different programs but they tend to share certain characteristics. They restrict digestible carbohydrate consumption to 50 or fewer grams a day, sometimes under 20 grams. This totally eliminates or drastically reduces some foods, such as grains, beans, starchy vegetables (corn, potatoes, peas, etc), milk, and sugar. Nor can you have products made from these, such as bread, cookies, pies, cakes, potato and corn chips, and candy. You eat meat, eggs, fish, chicken, certain cheeses, nuts, low-carb vegetables (e.g., salad greens, broccoli, green beans, cauliflower), and oils. Total calorie consumption is not restricted; you count carb grams rather than calories. This is a radical change in eating for most people.

You’re may be wondering what “ketogenic” means. First, understand that your body gets nearly all its energy either from fats, or from carbohydrates like glucose and glycogen. In people eating normally, 60% of their energy at rest comes from fats. In a ketogenic diet, the carbohydrate content of the diet is so low that the body has to break down even more of its fat to supply energy needed by most tissues. Fat breakdown generates ketone bodies in the bloodstream. Hence, “ketogenic diet.” Some of the recent writers are using the phrase “nutritional ketosis” to summarize this metabolic state.

Ketogenic Versus Traditional Calorie-Restricted Dieting

Are there advantages to ketogenic diets for weight loss and management? Numerous recent studies have demonstrated superior weight-loss results with very-low-carb diets as compared to traditional calorie-restricted diets. Weight loss is often faster and more consistently in the range of one or two pounds (0.5 to 0.9 kg) a week. Very-low-carb dieters have less trouble with hunger. If you do get hungry, there’s always something you can eat. From a practical, day-to-day viewpoint, these diets can be easier to follow, with a bit less regimentation than calorie-restricted plans.

Ketogenic diets typically lower blood sugar levels, which is important for anyone with diabetes, prediabetes, and metabolic syndrome. We see higher levels of HDL cholesterol (the good kind), lower triglyceride levels, and a shift in LDL cholesterol to the “large fluffy” kind, all of which may reduce the risk of heart disease. Getting even further into the science weeds, very-low-carb diets reduce insulin levels in people who often have elevated levels (hyperinsulinemia), which may help reduce chronic diseases like type 2 diabetes, high blood pressure, some cancers, and coronary heart disease.  Clearly, ketogenic diets work well for a significant portion of the overweight population, but not for everybody.

Sounds great so far! So why aren’t very-low-carb diets used more often? Many dieters can’t live with the restrictions. Your body may rebel against the switch from a carbohydrate-based energy metabolism to one based on fats. Most of us live in a society or subculture in which carbohydrates are everywhere and they’re cheap; temptation is never-ending.

What Could Go Wrong on a Ketogenic Diet?

Very-low-carb ketogenic diets have been associated with headaches, bad breath, easy bruising, nausea, fatigue, aching, muscle cramps, constipation, and dizziness, among other symptoms.

“Induction flu” may occur around days two through five, consisting of achiness, easy fatigue, and low energy. Atkins dieters came up with the term. It usually clears up after a few days. Some people think of induction flu as a withdrawal syndrome from sugar or refined carbohydrate. My conception is that it’s simply an adjustment period for your body to switch from a carbohydrate-based energy system to one based on fat. Your body cells need time to rev up certain enzymes systems while mothballing other enzymes. To prevent or minimize induction flu, Drs. Stephen Phinney, Jeff Volek, and Eric Westman routinely recommend eating 1/2 tsp of table salt daily.

Very-low-carb ketogenic diets may have the potential to cause osteoporosis (thin, brittle bones), kidney stones, low blood pressure, constipation, gout, high uric acid in the blood, excessive loss of sodium and potassium in the urine, worsening of kidney disease, deficiency of calcium and vitamins A, B, C, and D, among other adverse effects. From a practical viewpoint, these are rarely seen, and many experts say they don’t occur in a well-designed ketogenic diet eaten by an essentially healthy person. I favor ketogenic diets designed by physicians or dietitians. In view of these potential adverse effects, however, it’s a good idea to run your ketogenic diet of choice by your personal physician before you get started. This is especially important if you have diabetes, chronic kidney or liver disease, or a history of gout, low blood pressure, or kidney stones.

Athletic individuals who perform vigorous exercise should expect a deterioration in performance levels during the first four weeks or so of any ketogenic very-low-carb diet. Again, the body needs that time to adjust to burning mostly fat for fuel rather than carbohydrate.

Competitive weightlifters or other anaerobic athletes (e.g., sprinters) may be hampered by the low muscle glycogen stores that accompany ketogenic diets. They may need more carbohydrates, perhaps 150 grams a day.

What’s Next After Losing Weight on a Ketogenic Diet?

A majority of folks eventually increase their carbohydrate consumption above 50 grams a day, which usually takes them out of nutritional ketosis. If they return to the typical 200-300 grams a day that most people eat, they’ll probably gain the lost weight back. Many have found, however, that they can go up to 70-100 grams and maintain at a happy weight. A well-designed program should give careful instructions on the transition out of ketosis and avoidance of regain.

To see a ketogenic diet I designed for my patients, visit:

http://diabeticmediterraneandiet.com/ketogenic-mediterranean-diet/

Steve Parker, M.D.

Steve Parker, M.D., is a leading medical expert on the Mediterranean diet and creator of the world’s first low-carb Mediterranean diet.  He has three decades’ experience practicing Internal Medicine and counseling on effective weight-loss strategies.  Dr. Parker is the author of “The Advanced Mediterranean Diet: Lose Weight, Feel Better, Live Longer (2nd Edition),“Conquer Diabetes and Prediabetes: The Low-Carb Mediterranean Diet, “ and “KMD: Ketogenic Mediterranean Diet.”

Are Low-Carb Diets More Effective Than Others?

DietDoctor Andreas Eenfeldt has a list of 16 scientific studies suggesting the superiority of low-carb diets for weight loss. I hope he keeps updating it. Here it is.

For my version of a low-carb diet, see KMD: Ketogenic Mediterranean Diet or Advanced Mediterranean Diet (2nd Ed.). The latter book also has a traditional “balanced” calorie-controlled diet with greater variety than a very low-carb diet. Ketogenic diets are getting a boost recently from Dr. Georgia Ede, Dr. Peter Attia, and the Livin’ La Vida Low-Carb Man, Jimmy Moore.

Steve Parker, M.D.

Too Much Mouse and Molecular Biochemistry!

That’s my primary assessment of an article I read in Current Opinion on Clinical Nutrition and Metabolic Care.  The title is “Low-carbohydrate ketogenic diets, glucose homeostasis, and nonalcoholic fatty liver disease.”

Don't assume mouse physiology is the same as human's

Don’t assume mouse physiology is the same as human’s

The article’s more about mice than my patients.

The authors share some stats about nonalcoholic fatty liver disease (NAFLD):

  • the earliest stage is fat build-up in the liver
  • 15% of the nonobese population has NAFLD
  • 65% of the obese have NAFLD
  • it can progress to an inflammatory disorder (nonalcoholic steatohepatitis (NASH)
  • about two out of 10 NASH patients progress to cirrhosis within 10 years
  • NAFLD is an independent predictor of heart and vascular disease, an even stronger predictor than overall body fat mass (even visceral fat)
  • insulin resistance is strongly linked to NAFLD

The Washington University School of Medicine authors say good things about low-carbohydrate ketogenic diets for weight loss and seizure control.  They spend the rest of the article talking about rodent physiology and lab chows—right up Carbsane Evelyn‘s alley.  But not mine.  Bores me to tears.

They do mention the small Browning study that showed a very-low-carb ketogenic diet superior to a calorie-restricted diet for reducing liver fat in humans. Weight loss by various methods is a standard recommendation for humans with NAFLD; I wouldn’t be surprised multiple different diets worked.  It may be the weight loss, not the diet, that does the trick.  We have just one human study thus far indicating a ketogenic diet is more effective short-term.

Here’s the full Browning study if you care to read it yourself.

If I were obese and had NAFLD, I’d go on a very-low-carb ketogenic diet (like this one).

Steve Parker, M.D.

Reference:  Schugar, Rebecca, and Crawford, Peter.  Low-carbohydrate ketogenic diets, glucose homeostasis, and nonalcoholic fatty liver disease.  Curr Opin Clin Nutr Metab Care, 2012, vol. 15.  doi: 10.1097/MCO.0b013e3283547157

Dietitian Franziska Spritzler’s Six-Month Ketogenic Diet Trial Results

Steve Parker MD, Advanced Mediterranean Diet

Two diet books in one: 1) portion control, and 2) ketogenic

Ketogenic diets help many folks lose excess weight, return blood sugar levels toward normal, and move HDL cholesterol and triglycerides to a healthier range. I include a ketogenic diet as an option in my Advanced Mediterranean Diet (2nd Ed.). They are not for everybody.

Read about Franziska Spritzler’s experience with a ketogenic diet (not my version). Some quotes:

Well, after consistently consuming 30-45 grams of net carbs a day for six months, I have only positive things to say about my very-low-carb experience. Not only are my blood sugar readings exactly where they should be — less than 90 fasting and less than 130 an hour after eating — but I truly feel healthier,  less stressed, and more balanced than ever.

My diet consists of lots of fat from avocados, nuts and nut butters, olive oil, and cheese; moderate amounts of fish, chicken, beef, Greek yogurt, and eggs; and at least one serving of nonstarchy vegetables at every meal and a small serving of berries at breakfast.  It’s truly a rich, satisfying, and luxurious way to eat.

Does Diet Affect Age-Related Memory Loss and Dementia Risk?

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

Don’t wait to take action until it’s too late

High blood insulin levels and insulin resistance promote age-related degeneration of the brain, leading to memory loss and dementia according to Robert Krikorian, Ph.D.  He’s a professor in the Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati Academic Health Center.  He has an article in a recent issue of Current Psychiatry – Online.

Proper insulin signaling in the brain is important for healthy functioning of our brains’ memory centers.  This signaling breaks down in the setting of insulin resistance and the associated high insulin levels.  Dr. Krikorian makes much of the fact that high insulin levels and insulin resistance are closely tied to obesity.  He writes that:

Waist circumference of ≥100 cm (39 inches) is a sensitive, specific, and independent predictor of hyperinsulinemia for men and women and a stronger predictor than body mass index, waist-to-hip ratio, and other measures of body fat.

Take-Home Points

Dr. Krikorian thinks that dietary approaches to the prevention of dementia are effective yet underutilized.  He mentions reduction of insulin levels by restricting calories or a ketogenic diet: they’ve been linked with improved memory in middle-aged and older adults.

Dr. K suggests the following measures to prevent dementia and memory loss:

  • eliminate high-glycemic foods like processed carbohydrates and sweets
  • replace high-glycemic foods with fruits and vegetables (the higher polyphenol intake may help by itself)
  • certain polyphenols, such as those found in berries, may be particularly helpful in improving brain metabolic function
  • keep your waist size under 39 inches, or aim for that if you’re overweight

I must mention that many, perhaps most, dementia experts are not as confident  as Dr. Krikorian that these dietary changes are effective.  I think they are, to a degree.

The Mediterranean diet is high in fruits and vegetables and relatively low-glycemic.  It’s usually mentioned by experts as the diet that may prevent dementia and slow its progression.

Read the full article.

I’ve written before about how blood sugars in the upper normal range are linked to brain degeneration.  Dr. Krikorian’s recommendations would tend to keep blood sugar levels in the lower end of the normal range.

Steve Parker, M.D.

PS: Speaking of dementia and ketogenic, have you ever heard of the Ketogenic Mediterranean Diet?  (Free condensed version here.)