Cyclical Ketogenic Diets Review

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Introduction to the ketogenic diet

Many readers may not be familiar with the ketogenic diet. This chapter discusses some general ideas about ketogenic diets, as well as defining terms that may be helpful. In the most general terms, a ketogenic diet is any diet that causes ketone bodies to be produced by the liver, shifting the body's metabolism away from glucose and towards fat utilization. More specifically, a ketogenic diet is one that restricts carbohydrates below a certain level (generally 100 grams per day), inducing a series of adaptations to take place. Protein and fat intake are variable, depending on the goal of the dieter. However, the ultimate determinant of whether a diet is ketogenic or not is the presence (or absence) of carbohydrates.

Fuel metabolism and the ketogenic diet

Ketone bodies are a by-product of the incomplete breakdown of FFA in the liver. They serve as a non-carbohydrate, fat-derived fuel for tissues such as the brain. When ketone bodies are produced at accelerated rates, they accumulate in the bloodstream, causing a metabolic state called ketosis to develop. Simultaneously, there is a decrease in glucose utilization and production. Along with this, there is a decrease in the breakdown of protein to be used for energy, referred to as 'protein sparing'. Many individuals are drawn to ketogenic diets in an attempt to lose bodyfat while sparing the loss of lean body mass.

Hormones and the ketogenic diet

Ketogenic diets cause the adaptations described above primarily by affecting the levels of two hormones insulin and glucagon. Insulin is a storage hormone, responsible for moving nutrients out of the bloodstream and into target tissues. For example, insulin causes glucose to be stored in muscle as glycogen, and FFA to be stored in adipose tissue as triglycerides. Glucagon is a fuel-mobilizing hormone, stimulating the body to break down stored glycogen, especially in the liver, to provide glucose for the body.

Exercise and the ketogenic diet

As with any fat-loss diet, exercise will improve the success of the ketogenic diet. However, a diet devoid of carbohydrates is unable to sustain high-intensity exercise performance although low-intensity exercise may be performed. For this reason, individuals who wish to use a ketogenic diet and perform high-intensity exercise must integrate carbohydrates without disrupting the effects of ketosis. Two modified ketogenic diets are described in this book which approach this issue from different directions. The targeted ketogenic diet (TKD) allows carbohydrates to be consumed immediately around exercise, to sustain performance without affecting ketosis. The cyclical ketogenic diet (CKD) alternates periods of ketogenic dieting with periods of high-carbohydrate consumption. The period of high-carbohydrate eating refills muscle glycogen to sustain exercise performance.

Changes in body composition Chapter 7 Other effects of the ketogenic diet

To address the physiology behind the ketogenic diet, a number of topics must be discussed. Chapter 3 discusses the utilization of various fuels glucose, protein, fat, ketones. Although not specific to the ketogenic diet, this provides the background to understand the following chapters. Chapters 4 and 5 address the topics of ketone bodies, ketogenesis, as well as the adaptations which are seen during the ketogenic diet. These two chapters are among the most technical in the book but are critical to understanding the basis for the ketogenic diet. Many of the adaptations seen are well-established, others less so. To avoid turning this into an undergraduate level biochemistry discussion, many of the smaller details have been omitted. Interested readers are encouraged to examine the references cited, especially the recent review papers. Chapter 6 addresses the question of whether a ketogenic diet causes greater, weight, water, fat, and protein losses compared to a more traditional fat...

Do ketogenic diets spare more nitrogen than nonketogenic diets

Most studies comparing ketogenic to non-ketogenic diets are done at very low calorie levels (VLCD, below 600 cal day). These have limited applicability to an individual dieting at 10-20 below maintenance levels as advocated in this book for reasons discussed in detail below. All that can be said from most of these studies is that a non-ketogenic diet will spare nitrogen better than a ketogenic diet as long as the diet periods are less than three weeks (13,16,19,21). The problem being that diets are rarely used for a period as short as three weeks in the real world. Some studies show greater nitrogen sparing for the ketogenic diet (22-24) while others show no advantage (21,23,25) and others show less nitrogen sparing (13,15,26). At higher calorie levels (maintenance to 1200 calories), there are few studies. One study at 1200 calories found less lean body mass (LBM) loss for the higher carbohydrate diets (27) while another found no difference in LBM losses (28). A final study done at...

The Standard Ketogenic Diet

The standard ketogenic diet (SKD) is what most think of as the ketogenic diet. It is a diet low in carbohydrate, and moderate-high in both protein and fat. Since the SKD forms the basis of the next two diets, it is discussed in detail. This includes a discussion of the effects of the macronutrients (carbohydrate, protein and fat) on ketosis, as well as discussions of how to determine optimal carbohydrate, protein and fat intake. Additionally, the effects of alcohol and other nutritional substances (such as caffeine and aspartame) on ketosis is discussed.

Carbohydrates and the ketogenic diet

In addition to the standard ketogenic diet (SKD), this book also details two modifications which have been made to the SKD. As discussed in forthcoming chapters on exercise, a SKD cannot sustain high-intensity exercise performance such as weight training or high-intensity aerobic training and carbohydrates must be integrated to the SKD in some fashion. There are two primary types of 'modified ketogenic diets' which incorporate carbohydrate intake within the structure of a SKD. The first of these is the Targeted Ketogenic Diet (TKD) in which individuals consume carbohydrates around exercise only. This allows for a maintenance of exercise performance and glycogen resynthesis without interrupting ketosis for long periods of time. The second type of 'modified ketogenic diet' is the Cyclical Ketogenic Diet or CKD. The CKD alternates periods of a ketogenic diet (generally 5-6 days) with periods of high carbohydrate intake (1-2 days). Typically the TKD is used by those individuals who either...

The Cyclical Ketogenic Diet CKD

As with the TKD, the CKD attempts to harness the effects of a ketogenic diet while maintaining exercise performance. However, rather than providing carbohydrates only around exercise, the CKD inserts a one- or two-day period of high carbohydrate eating to refill muscle glycogen. This means that for the CKD to work, muscle glycogen must be depleted fully each week. A few calculations which appear below show that full depletion of muscle glycogen requires a fairly large amount of training. This means that the CKD is not appropriate for beginning exercisers or those who are unable to perform the amount of training necessary. The standard format for a CKD is to alternate 5-6 days of ketogenic dieting with 1-2 days of high carbohydrate eating, although other variations can be developed. Individuals have experimented with longer cycles (10-12 days) as well as shorter cycles (3-4) days with good results. A 7 day cycle is more a choice of convenience than anything physiological, since it fits...

Low Carb Diets For The Obese

Over the past ten years, a low fat diet emphasizing plenty of energy rich complex carbohydrates has been the diet regiment that Americans have adopted in a quest for a fat free body. Combined with exercise, a high carbohydrate diet, one that includes foods like potatoes, yams, beans, whole grain breads and low calorie fruit has been used by countless millions to reduce fat stores. However, during the same time, the nation as a whole has become fatter than ever. Many who successfully subscribe to the high carbohydrate diet believe a low carb approach to fat loss is dietary suicide. For those who have failed to attain a low level of body fat using a high carbohydrate diet, and for those who have exercised religiously, hour upon hour, week after week, and have failed to attain a six-pack-rack of abdominals, hard glutes, and a low level of body fat, the low carb approach may be suited for you. For the obese, who have over 50 pounds to lose, this may be a fast and easy to use plan that...

Protein and Carb Requirements On A Low Carb Diet

Protein must remain high as dietary protein supplied, in higher amounts, can offset some of the muscle wasting effects associated with a low carb plan. On a low carb diet, I suggest protein consumption rise to 1.5 grams of protein for each pound of goal body weight. For example, the individual weighing 188 pounds and wishes to reduce to 158 pounds, protein intake should be roughly 237 grams a day (1.5 x 158 237). On days an individual is working out, protein intake should rise to as high as 1.75 grams per pound of goal body weight. In this case, 276 grams a day. And, if your a bodybuilder and carry a lot of muscle, you will need more protein, as high as 2.2 grams for each pound of goal body weight. Say a bodybuilder has a goal of weighing 180 pounds, he'd consumed 315 to 396 grams of protein a day. (1.75 to 2.2 grams per pound of goal body weight) the low carb dieter his state of ketosis. Basically, the user urinates into a paper cup and dips these small little sticks into the urine....

Zero carbohydrate or very low carbohydrate diets are the best way to lose body fat permanently

No diet issue has created more confusion and controversy than the low carbohydrate vs. high carbohydrate debate. However, it's true that some people lose weight more quickly on a low carbohydrate diet (that's not the same thing as saying carbohydrates are fattening.) It's also true that almost every bodybuilder or fitness competitor uses some variation of the low carb diet to prepare for competitions. Despite these facts, very low carb diets are not the ultimate answer to permanent weight loss. At worst they are unhealthy. At best they're a temporary tool that should be used only for short periods to achieve specific fat loss goals (preparing for bodybuilding competition, for example). 1) Very low carb diets are difficult to stick to. If you remove most of your carbohydrates from your diet for a long period of time, you're setting yourself up for a relapse. The more you cut back the carbs, the bigger the rebound will be when you put carbs back in. That's why 95 of people gain back all...

Section 4 Fatigue during interval training and the effects of a ketogenic diet

As stated, during exercise above lactate threshold, anaerobic glycolysis leads to a generation of lactic acid. During high intensity exercise of 20-60 seconds duration, lactic acid accumulation is the most likely cause of fatigue (13,14). At fatigue, glycogen levels in the muscle fibers typically remain high (15,16) further suggesting that fatigue is occurring from the buildup of waste products. Thus, it would not appear that a ketogenic diet would directly impair performance during this type of exercise as glycogen availability is not the limiting factor. During repeated bouts of high intensity exercise (i.e. sprint training), depletion of glycogen will become an important factor in fatigue (17). While on a ketogenic diet, although pH is rapidly normalized, there is a decrease in the body's buffering capacity due to lower bicarbonate levels (19,20,21,25). Since bicarbonate is used to buffer the lactic acid produced from anaerobic glycolysis, fatigue during a single interval may occur...

Section 5 Effects of the Ketogenic Diet on Weight Training

Relatively few studies have examined the effects of carbohydrate depletion on resistance training. Typically, researchers measure maximal force production during a single isometric contraction or muscular endurance during multiple rep sets during isokinetic exercise. Isokinetic exercise machines are special types of weight training equipment that control speed of movement. They are typically not found outside the laboratory and may not be an applicable model to normal strength training.

Long term ketogenic diet and high intensity activity

At this time, only one study (112) has examined high intensity exercise performance after long term adaptation to a ketogenic diet, finding no decrease in performance. As performance at higher intensities are generally determined by non-oxidative metabolism, it seems unlikely that long term adaptation to a ketogenic diet would have an effect on exercise of this type. Since no research on this topic exists, any long term effects on performance are purely speculative at this time. The main determinant in performance in weight training is probably muscle glycogen levels. Thus, the amount of work that can be performed in a given workout will depend on starting muscle glycogen levels.

Section 6 Longterm ketogenic diet and endurance activity

Although many studies have examined the effects of short-term glycogen depletion with a high fat diet, only a few have examined the long-term effects of a ketogenic diet on endurance performance. As we shall see, there appears to be a difference between short-term glycogen depletion and long-term ketogenic adaptation. Please note that these studies generally did not examine the effects of exercise on fat loss on a ketogenic diet. Rather, they simply examined what types of exercise could be sustained on a diet devoid of carbohydrates. Studies on longer term ketogenic (2 to 6 weeks) diets find either a maintenance (73,74) or increase (75,76) in endurance at low-intensity exercise (75 of maximum heart rate and below). At higher intensities (around 85 of maximum heart rate which is likely above the lactate threshold) performance decreases (77). As higher intensity exercise relies proportionally more on carbohydrate for fuel, this would be expected to occur. A recent review of the...

Section 1 Macronutrient intake on the ketogenic diet

Although discussed in detail in Chapter 8, the basic idea of calories and weight loss (as well as fat loss) is mentioned again here. One of the prime selling points of many low-carbohydrate diets is a dieter can lose weight while 'eating as much protein and fat as they like'. While this is loosely true, this was misinterpreted by dieters and physicians alike to claim that dieters would lose weight eating unlimited amounts of foods. This idea was criticized by the American Medical Association (AMA) as it seemed to suggest that a ketogenic diet could somehow break basic laws of thermodynamics (1). The AMA was correct that it is impossible for dieter's to lose weight while consuming unlimited calories. However, looking at the research on ketogenic diets, we see that most individuals will automatically reduce their caloric intake when they restrict carbohydrate to low levels. Therefore, in a sense individuals are losing weight eating 'as much as they like', it is simply that they are...

Ending a ketogenic diet

Some individuals may choose to remain on some form of a ketogenic (or low carbohydrate) diet indefinitely while others will not. For those who remain on a ketogenic diet, there are fewer issues involved in moving from fat loss maintenance. Either calories can be increased (in the form of dietary fat or carbohydrate) or activity levels can be decreased until fat loss stops. Since the long term health implications of ketogenic diets are not known, this book cannot recommend that a ketogenic diet be sustained indefinitely. For individuals who do move away from the ketogenic diet, there are more issues which need to be discussed including the physiological ramifications of adding carbohydrates back to the diet, maintaining bodyfat levels, etc. Each is discussed in this chapter. Most of the information presented here applies to individuals on a SKD or TKD. Due to the structure of the CKD, it has its own set of implications and consequences.

The Targeted Ketogenic Diet TKD

Having examined glycogen levels and glycogen depletion in the last chapter, the details of the first 'modified ketogenic diet' can now be discussed. The targeted ketogenic diet (TKD) is nothing more than the standard ketogenic diet (SKD) with carbohydrates consumed at specific times around exercise. This means that the general guidelines for constructing a SKD in chapter 9 should be used with the exception that more carbohydrates are consumed on days when exercise is performed. If fat loss is the goal, the number of calories consumed as carbohydrates should be subtracted from total calories, meaning that less dietary fat is consumed on those days. The TKD is based more on anecdotal experience than research. Invariably, individuals on a SKD are unable to maintain a high training intensity for reasons discussed in chapters 18 through 20. However, for a variety of reasons,some dieters choose not to do the full 1-2 day carb-up of the CKD (discussed in the next chapter). The TKD is a...

Starvation and the ketogenic diet

In one sense, the ketogenic diet is identical to starvation, except that food is being consumed. That is, the metabolic effects which occur and the adaptations which are seen during starvation are roughly identical to what is seen during a ketogenic diet. The primary difference is that the protein and fat intake of a ketogenic diet will replace some of the protein and fat which would otherwise be used for fuel during starvation. The response to total starvation has been extensively studied, arguably moreso than the ketogenic diet itself. For this reason the great majority of data presented below comes from studies of individuals who are fasting. With few exceptions, which are noted as necessary, the metabolic effects of a ketogenic diet are identical to what occurs during starvation.

Water loss on the ketogenic diet

A well established fact is that low-carbohydrate diets tend to cause a rapid loss of water in the first few days. This occurs for several reasons. First and foremost, glycogen is stored along with water in a ratio of three grams of water for every gram of stored carbohydrate (37). As glycogen is depleted, water is lost. For large individuals, this can represent a lot of weight. Due to confusions about weight loss and fat loss (see chapter 8), many individuals are drawn to low-carbohydrate diets specifically for the rapid initial loss of water weight. During the first few days of a ketogenic diet, water loss has been measured from 4.5 to 15 lbs (17,39-41). Although transient, this rapid initial weight loss can provide psychological incentive for dieters, which may mean greater compliance with the diet. In one study of subjects on a very-low-calorie ketogenic diet adhered to their diet much more than individuals consuming more carbohydrate, and who lost less weight (8). Regardless of...

Ketogenic diets and bodybuildersathletes

Low carbohydrate diets were used quite often in the early years of bodybuilding (the fish and water diet). As with general fat loss, the use of low carbohydrate, ketogenic diets by athletes fell into disfavor as the emphasis shifted to carbohydrate based diets. As ketogenic diets have reentered the diet arena in the 1990's, modified ketogenic diets have been introduced for athletes, primarily bodybuilders. These include so-called cyclical ketogenic diets (CKD's) such as The Anabolic Diet (20) and Bodyopus (21). In the early 1990's, Dr. Mauro DiPasquale, a renowned expert on drug use in sports, introduced The Anabolic Diet (AD). This diet alternated periods of 5-6 days of low carbohydrate, moderate protein, moderate high fat eating with periods of 1-2 days of unlimited carbohydrate consumption (20). The major premise of the Anabolic Diet was that the lowcarb week would cause a 'metabolic shift' to occur, forcing the body to use fat for fuel. The high carb consumption on the weekends...

Other effects of the ketogenic diet

The ketogenic diet has numerous metabolic effects, many of which are discussed in the previous chapters. However there are numerous other metabolic effects that need to be discussed as well as concerns which are typically raised regarding the ketogenic diet. This chapter is a catch-all to discuss any effects on the body that have not been discussed in previous chapters. It examines the effects (and side-effects) of the metabolic state of ketosis on the human body. As well, some of the major health concerns which have been voiced regarding the ketogenic diet are addressed here. There are ultimately two main concerns regarding the ketogenic diet in terms of health risks. The first is the potential negative effects of the 'high protein' intake of the ketogenic diet. Additionally, there is the effect of high levels of ketones. They are discussed as needed below. There are few studies of the long term effects of a ketogenic diet. One of the few, which followed two explorers over a period...

Epilepsy compiled from references

The ketogenic diet has been used to treat a variety of clinical conditions, the most well known of which is childhood epilepsy. Writings as early as the middle ages discuss the use of fasting as a treatment for seizures. The early 1900's saw the use of total fasting as a treatment for seizures in children. However, fasting cannot be sustained indefinitely and only controls seizures as long as the fast is continued. Due to the problems with extended fasting, early nutrition researchers looked for a way to mimic starvation ketosis, while allowing food consumption. Research determined that a diet high in fat, low in carbohydrate and providing the minimal protein needed to sustain growth could maintain starvation ketosis for long periods of time. This led to development of the original ketogenic diet for epilepsy in 1921 by Dr. Wilder. Dr. Wilder's ketogenic diet controlled pediatric epilepsy in many cases where drugs and other treatments had failed. The ketogenic diet as developed by Dr....

Section 1 Bodily Fuel Stores

The body has three storage depots of fuel which it can tap during periods of caloric deficiency protein, which can be converted to glucose in the liver and used for energy carbohydrate, which is stored primarily as glycogen in the muscle and liver and fat , which is stored primarily as body fat. A fourth potential fuel is ketones. Under normal dietary conditions, ketones play a non-existent role in energy production. In fasting or a ketogenic diet, ketones play a larger role in energy production, especially in the brain. A comparison of the various fuels available to the body appear in table 1.

Section 2 Relationships in fuel use

The difference in the proportion of each fuel used will depend on the metabolic state of the body (i.e. aerobic exercise, weight training, normal diet, ketogenic diet fasting). Exercise metabolism is addressed in later chapters and we are only concerned here with the effects of dietary changes on fuel utilization. In general, tissues of the body will use a given fuel in proportion to its concentration in the bloodstream. So if a given fuel (i.e. glucose) increases in the bloodstream, the body will utilize that fuel in preference to others. By the same token, if the concentrations of a given fuel decrease in the bloodstream, the body will use less of that fuel. By decreasing carbohydrate availability, the ketogenic diet shifts the body to using fat as its primary fuel.

Glucose and protein use

With normal glucose availability, there is little gluconeogenesis from the body's protein stores. This has led many to state that carbohydrate has a 'protein sparing' effect in that it prevents the breakdown of protein to make glucose. While it is true that a high carbohydrate intake can be protein sparing, it is often ignored that this same high carbohydrate also decreases the use of fat for fuel. Thus in addition to being 'protein sparing', carbohydrate is also 'fat sparing' (3). If glucose requirements are high but glucose availability is low, as in the initial days of fasting, the body will break down its own protein stores to produce glucose. This is probably the origin of the concept that low carbohydrate diets are muscle wasting. As discussed in the next chapter, an adequate protein intake during the first weeks of a ketogenic diet will prevent muscle loss by supplying the amino acids for gluconeogenesis that would otherwise come from body proteins. Since protein breakdown is...

Relationships between carbohydrates and fat

As long as muscle and liver glycogen stores are not completely filled, the body is able to store or burn off excess dietary carbohydrates. Of course this process occurs at the expense of limiting fat burning, meaning that any dietary fat which is ingested with a high carbohydrate intake is stored as fat. The most likely scenario in which this would occur would be one in which an individual was inactive and consuming an excess of carbohydrates calories in their diet. As well, the combination of inactivity with a very high carbohydrate AND high fat diet is much worse in terms of fat gain. With chronically overfilled glycogen stores and a high carbohydrate intake, fat utilization is almost completely blocked and any dietary fat consumed is stored. This has led some authors to suggest an absolute minimization of dietary fat for weight loss (15,16). The premise is that, since incoming carbohydrate will block fat burning by the body, less fat must be...

Quantity of nutrients consumed

The consumption of alcohol will almost completely impair the body's use of fat for fuel. Similarly the consumption of carbohydrate affects the amount of fat used by the body for fuel. A high carbohydrate diet decreases the use of fat for fuel and vice versa (15). Thus, the greatest rates of fat oxidation will occur under conditions when carbohydrates are restricted. As well, the level of muscle glycogen regulates how much fat is used by the muscle (20,21), a topic discussed in chapter 18. Using exercise and or carbohydrate restriction to lower muscle and liver glycogen levels increases fat utilization (22).

What are ketone bodies

The three ketone bodies are acetoacetate (AcAc), beta-hydroxybutyrate (BHB) and acetone. AcAc and BHB are produced from the condensation of acetyl-CoA, a product of incomplete breakdown of free fatty acids (FFA) in the liver. While ketones can technically be made from certain amino acids, this is not thought to contribute significantly to ketosis (1). Roughly one-third of AcAc is converted to acetone, which is excreted in the breath and urine. This gives some individuals on a ketogenic diet a 'fruity' smelling breath.

Functions of ketones in the body

Ketones serve a number of functions in the body. The primary role, and arguably the most important to ketogenic dieters, is to replace glucose as a fat-derived fuel for the brain (3,4). A commonly held misconception is that the brain can only use glucose for fuel. Quite to the contrary, in situations where glucose availability is limited, the brain can derive up to 75 of its total energy requirements from ketone bodies (3). brain (see chapter 5 for more detail) (6). While many tissues of the body (especially muscle) use a large amount of ketones for fuel during the first few weeks of a ketogenic diet, most of these same tissues will decrease their use of ketones as the length of time in ketosis increases (4). At this time, these tissues rely primarily on the breakdown of free fatty acids (FFA). In practical terms, after three weeks of a ketogenic diet, the use of ketones by tissues other than the brain is negligible and can be ignored.

Section 2 Ketogenesis and the two site model

The formation of ketone bodies, called ketogenesis, is at the heart of the ketogenic diet and the processes involved need to be understood. As described in the previous chapter, the primary regulators of ketone body formation are the hormones insulin and glucagon. The shift that occurs in these two hormones, a decrease in insulin and an increase in glucagon is one of the major regulating steps regulating ketogenesis.

What does ketosis represent

The development of ketosis indicates two things. First, it indicates that the body has shifted from a metabolism relying primarily on carbohydrates for fuel to one using primarily fat and ketones for fuel (4). This is arguably the main goal of the ketogenic diet to cause an overall metabolic shift to occur in the body. The reasons this shift may be desirable are discussed in the next chapter.

Changes in hormones and fuel availability

Although some mention is made in the discussions below of the adaptations seen during this time period, most of the major adaptations to ketosis start to occur by the third day, continuing for at least 3 weeks (4-6). During the first 3 days of fasting, blood glucose drops from normal levels of 80-120 mg dl to roughly 65-75 mg dl. Insulin drops from 40-50 pU ml to 7-10 pU ml (5,7,8). Both remain constant for the duration of the fast. One thing to note is that the body strives to maintain near-normal blood glucose levels even under conditions of total fasting (5). The popularly held belief that ketosis will not occur until blood glucose falls to 50 mg dl is incorrect. Additionally, the popular belief that there is no insulin present on a ketogenic diet is incorrect (7). One difference between fasting and a ketogenic diet is that the slight insulin response to dietary protein will cause blood glucose to be maintained at a slightly higher level, approximately 80-85 mg dl (1). This most...

The brains glucose requirements

Please note that the following discussion is only truly relevant to individuals on a Standard Ketogenic Diet (SKD) who are not exercising. However the same information also applies to individuals using a TKD or CKD as some period is spent in ketosis. The impact and implications of exercise on carbohydrate requirements is discussed in later chapters.

Section 4 Ketosis and protein sparing

The question which needs to be answered is what mechanisms exist for ketones (or ketosis) to spare protein. There are at least four possible mechanisms through which ketogenic diets may spare protein, three of which are well established in the literature, the fourth less so. They are discussed in more detail below.

Decreasing the bodys glucose requirements

That is, the development of ketosis is a critical aspect of preventing excessive nitrogen losses during periods of caloric insufficiency. This suggests that non-ketogenic low-carbohydrate diets (frequently used by bodybuilders) may actually cause greater protein losses by preventing the body from maximizing the use of fat for fuel, which is addressed in chapter 6 .

Affecting thyroid levels

A fourth possible mechanism by which ketosis may reduce protein breakdown involves the thyroid hormones, primarily triiodothyronine (T3). T3 is arguably one of the most active hormones in the human body (42-44). While most think of T3 simply as a controller of metabolic rate, it affects just about every tissue of the body including protein synthesis. A decrease in T3 will slow protein synthesis and vice versa. As a side note, this is one reason why low carbohydrate diets are not ideal for individuals wishing to gain muscle tissue the decrease in T3 will negatively affect protein synthesis. Below 800 calories per day, even if 100 of those calories come from carbohydrate, T3 levels drop (47). Within days of starting a ketogenic diet, T3 drops quickly. This is part of the adaptation to prevent protein losses and the addition of synthetic T3 increases nitrogen losses during a ketogenic diet (1). In fact the ability to rapidly decrease T3 levels may be one determinant of how much protein...

Changes in body composition

Having discussed the primary metabolic adaptations which occur during ketosis in the previous chapter, we can now examine the effects of ketogenic diets on body composition. The first issue to examine is the effect of food intake on ketosis. This will lead into an examination of protein sparing on a ketogenic diet, as well as issues involving weight, water, and fat loss. The question to be answered is whether a ketogenic diet does in fact cause greater fat loss with less loss of body protein than a more 'balanced' diet. Unfortunately, the lack of appropriate studies, as well as a high degree of variability in study subjects, make this a difficult question to answer unequivocally. Issues relating to water loss on a ketogenic diet are discussed as well.

Section 1 Macronutrients and Ketosis

Despite the generally 'high fat' nature of the ketogenic diet, or at least how it is perceived, dietary fat intake has a rather minimal effect on ketosis per se. Fat intake will primarily affect how much bodyfat is used for fuel. Although alcohol has been discussed within the context of ketoacidosis, the effects of alcohol intake on the state of ketosis are discussed again here.

How much dietary protein is necessary to prevent nitrogen losses

Assuming zero carbohydrate intake, during the first 3 weeks of a ketogenic diet a protein intake of 150 grams per day should be sufficient to achieve nitrogen balance. Therefore, regardless of bodyweight, the minimum amount of protein which should be consumed during the initial three weeks of a ketogenic diet is 150 grams per day.

Problems with nitrogen balance

Although nitrogen balance is one of the best methods for determining muscle loss while dieting, there are still problems. First and foremost, there tends to be a great degree of variability in total nitrogen losses among subjects in diet studies. For example, one study found that daily nitrogen losses on a ketogenic diet varied among the subjects between 1 gram of nitrogen day and 6 grams of nitrogen day. This represents a difference in bodily protein breakdown of 6-36 grams of protein day (10). Unfortunately most diet studies report nitrogen balances as average values for differing diet groups. This tends to overstate either how well or how poorly a diet works to spare protein. If one individual loses a significant amount of nitrogen while another loses very little, reporting an average does not provide accurate information.

Section 4 Water and weight loss

Having discussed the topic of nitrogen sparing we can finally examine the effects of ketogenic diets on the other aspects of body composition water, weight and fat loss. The question then to be answered is whether a ketogenic diet will cause more weight and or fat loss than a non-ketogenic diet with the same calories. As with the sections on protein sparing, study methodology makes makes it impossible to absolutely answer this question. Prior to discussing the effects of the ketogenic diet on body composition, a few comments about the various studies cited by both the pro- and anti-ketogenic groups are in order.

Problems with the studies

Most of the early ketogenic diet studies looked at weight loss only, making no distinction between fat, water and muscle loss. As discussed in chapter 8, a dieter's goal should be maximal fat loss with minimal muscle loss. Since water weight can be gained or lost quickly, it should not be used as the factor to determine whether a ketogenic or balanced diet is the optimal approach. Likewise, many early studies, which are frequently cited by pro-ketogenic authors, confused water loss with fat loss due to methodological problems. These studies should not be considered as evidence either for or against a ketogenic diet. Many early diet studies were extremely short in duration, five to ten days in some cases. This makes drawing valid conclusions about the effectiveness of a given diet approach impossible as results are confounded by the rapid water losses which occurs in the first few days. In very short term studies, a ketogenic diet will almost always show greater weight loss because of...

Section 1 Fat loss versus Weight loss

Most individuals starting a diet as well as most diet books tend to focus solely on one measure of progress changes in bodyweight. The scale has been used for years as the only indicator of whether or not a diet is working. While this is a problem on any diet (for reasons discussed below), it can be of even greater importance when discussing low-carbohydrate diets and low-carbohydrate diet studies, due to shifts in water weight. To accurately know whether a diet is working or not, we have to be more specific in our measurements than simply bodyweight. Individuals beginning a weight training program often gain one or two pounds by the scale from increased water storage in the muscles. This weight gain is temporary and should not be confused with true fat gain. Similarly, consuming carbohydrates after a period of low carbohydrate dieting will cause a large, but transient, increase in bodyweight from increased body water. This weight gain also should not be confused with true fat gain....

Section 2 Carbohydrates and the SKD

Although up to 100 grams of carbohydrate will allow ketosis to develop, it would be rare to see ketones excreted in the urine at this level of intake. Since the only measure of ketosis available to ketogenic dieters are Ketostix (tm) carbohydrates must be restricted below this level if ketosis is to be measured. As a general rule of thumb, dietary carbohydrates should be below 30 grams per day for ketosis to be rapidly established and for ketones to be lost in the urine. An extremely low carbohydrate intake is relatively more important for those individuals following the CKD, who only have five or six days to establish ketosis. In this case, carbohydrate intake should be minimized as much as possible (meaning that protein intake must be adequate) during the first few days of each cycle so that ketosis will occur as quickly as possible. Individuals on a TKD follow a separate set of rules for daily carbohydrate intake which is discussed in chapter 11. Since our wish is to minimize...

Section 3 Protein and the SKD

Having discussed the details of carbohydrate intake on a standard ketogenic diet (SKD) last chapter, we can now discuss issues pertaining to protein. Although carbohydrate intake is arguably the most important aspect of successfully inducing ketosis, protein intake is extremely important in order to prevent muscle loss. While an easy solution is to simply eat as much protein as possible, too much protein can prevent ketosis as well, disrupting the adaptations which ketogenic dieters seek. Therefore, protein intake must fall within a narrow range high enough to prevent muscle loss but low enough that ketosis is not disrupted. A common criticism of the ketogenic diet is that ketosis is catabolic. This is true in that any diet which is restricted in calories is catabolic . The question, addressed in chapters 5 and 6, is whether the ketogenic diet is inherently more catabolic than other dietary approaches. As discussed in chapter 6, one of the problems with many diet studies comparing...

Section 4 Fat and the SKD

Having discussed the details of carbohydrate and protein amounts in the last two chapters, the only remaining macronutrient to be discussed is dietary fat. Although a ketogenic diet can be constructed with only protein and a small amount of carbohydrate, the caloric intake is so low that metabolic slowdown will occur. Fat is in essence a caloric ballast, a nutrient which has a relatively neutral effect on insulin levels or ketosis, and which is used to adjust calories. With regard to blood cholesterol levels, readers need to understand that the liver produces more cholesterol (up to 2000 milligrams per day) than most individuals would ever consume, even on a ketogenic diet. Additionally, when dietary cholesterol intake increases, the body's synthesis of cholesterol will typically go down. When dietary cholesterol intake goes down, the body's synthesis of cholesterol typically goes up. This supports the contention that dietary cholesterol generally has little impact on blood...

Section 1 Glycogen levels

Muscle glycogen is measured in millimoles per kilogram of muscle (mmol kg). An individual following a normal mixed diet will maintain glycogen levels around 80-100 mmol kg. Athletes following a mixed diet have higher levels, around 110-130 mmol kg (1). On a standard ketogenic diet, with aerobic exercise only, muscle glycogen levels maintain around 70 mmol kg with about 50 mmol kg of that in the Type I muscle fibers (2,3).

Amounts types and timing of carbs

One concern of many SKDers (especially those who are using a ketogenic diet to control conditions such as hyperinsulinemia) is the potential insulin response from carbohydrate ingestion on a TKD. Generally speaking, insulin levels decrease during exercise. Exercise training itself improves insulin sensitivity as does glycogen depletion (3,4). So hyperinsulinemia should not be a problem during exercise for individuals consuming carbs pre-workout.

Duration and amount of the carbload

With 36 hours of carb-loading, roughly 150 compensation can occur, reaching levels of 150-160 mmol kg of muscle glycogen. To achieve greater levels of muscle glycogen (175 mmol kg or more) generally requires 3-4 days of high carbohydrate eating following exhaustive exercise (2).

Fat gain during the carbup

Additionally, the excess carbohydrates which were not stored as glycogen were used for energy (22). In general, the synthesis of fat from glycogen (referred to as de novo lipogenesis) in the short term is fairly small (23,24). During carbohydrate overfeeding, there is a decrease in fat use for energy. Most fat gain occurring during high carbohydrate overfeeding is from storage of excessive fat intake (25). Therefore, as long as fat intake is kept relatively low (below 88 grams) during the carb-up phase of the CKD, there should be minimal fat regain. In a similar study, individuals consumed a low-carb, high fat diet for 5 days and then consumed very large amounts of carbohydrates (700 to 900 grams per day) over a five day period. During the first 24 hours, with a carbohydrate intake of 700 grams and a fat intake of 60 grams per day, there was a fat gain of only 7 grams. Collectively, these two studies suggest that the body continues to use bodyfat for fuel during the first 24 hours of...

Long term effects of a CKD

Although the myriad effects of ketogenic diets are discussed in detail in chapter 7, another concern is what long term metabolic effects a CKD will have. There is unfortunately no answer. It seems logical that any long-term adaptations to ketosis will be reversed when a non-ketogenic diet is followed for a sufficient period of time but this is mere speculation. Anecdotally, it appears that some of the adaptations to ketogenic diets continue even after a non-ketogenic diet has been followed. The easiest one to examine is the aforementioned fatigue and 'mental fuzziness' during the first week. In general, individuals (including this author) returning to a CKD after a period of more 'balanced' dieting do not experience the same level of fatigue as when they first started the diet. This seems to suggest that some of the changes in the brain (especially with regards to ketone usage) may be longer lasting. Once again, the lack of long term data prevents any conclusions from being drawn....

A recap of the lowcarb week

Recall from previous chapters that the ketogenic part of the CKD lowers insulin and thyroid levels, while raising glucagon. The data on GH is less clear, with some studies showing an increase, others a decrease. The effects of the ketogenic diet on testosterone and cortisol are less established. Thus, the overall effect of the ketogenic phase is a catabolic one, although ketosis appears to be selectively catabolic (i.e. the protein sparing effect of ketosis).

Insulin and amino acids

When carbohydrates are refed after even a few days of a ketogenic diet, the insulin response is higher than it would be under normal dietary conditions (38). This is probably due to the slight insulin resistance which occurs during a ketogenic diet, discussed in chapter 7. Hyperinsulinemia also increases the transport of some amino acids into muscle (39). These metabolic effects might contribute to muscle growth during the carb-up.

Improve the nutrient quality of the lowcarb week

The nature of the ketogenic diet is such that most individuals tend to consume a lot of saturated fats while on the diet. Substituting some of the saturated fat intake inherent to the ketogenic diet with unsaturated fats such as fish oils and vegetable oils, may increase thermogenesis (the burning of calories to produce heat) and increase fat loss. Many individuals report a significant amount of bodily warmth following a meal high in unsaturated fats, probably due to increased thermogenesis. Note that this further limits the food choices available on a ketogenic diet.

Cycle calories throughout the week

Many individuals have found success by cycling caloric intake while on a ketogenic diet. If we use a rough guideline of 12 cal lb as an average caloric intake during the lowcarb week, an individual might alternate a day at slightly lower calorie levels (for example one day at 11 calories pound) with days at slightly higher calorie levels (14 calories per pound) to get fat loss going again.

Section 2 Measuring ketosis

Whether correct or not, many ketogenic diets tend to live or die by the presence of ketones in their urine. The presence of ketosis, which is indicative of lipolysis can be psychologically reassuring to ketogenic dieters. However it should be noted that one can be in ketosis, defined as ketones in the bloodstream, without showing urinary ketones. Since dieters will not be able to determine blood ketones, other methods are necessary. The two measurement tools which most individuals will have access to are Ketostix (tm) and glucometers, which are small machines used by diabetics to measure blood glucose level. Both are discussed below.

How to use Ketostix tm

Ketostix (tm) seem to have their greatest use for individuals just starting the diet. After a period of time on a ketogenic diet, most individuals can 'feel' when they are in ketosis. Many individuals get a metallic taste in their mouth, or report a certain smell to their breath or urine, making Ketostix (tm) unnecessary.

Section 3 Tools For measuring your diet

There are only two items which are truly necessary for measuring the diet. The first and arguably the most important is some sort of calorie nutrient counter book. Many individuals are confused as to which foods have carbs in them and which foods do not. And while most foods are labeled with the proportions of carbohydrate, protein and fat many foods are not, especially meats and cheeses. In this case a food count book can be invaluable to ensure that carbohydrate intake stays low during a ketogenic diet. Although there are carbohydrate counter books available which only provide information on carbohydrate content, it is recommended that dieters obtain a book providing protein and fat gram information as well.

Final considerations

As stated previously, this book is not meant to argue for or against the ketogenic diet as the ideal diet for weight fat loss or any other application. Rather it is an attempt to present a comprehensive account of what occurs during a ketogenic diet, and to dispel the many misconceptions surrounding the state of dietary ketosis. Additionally, specific guidelines have been offered for those individuals who have decided to do a ketogenic diet. As discussed in chapter 6, it is impossible to state unequivocally whether a ketogenic diet is better or worse in terms of fat loss and protein sparing than a carbohydrate-based diet with a similar calorie level. This is largely due to the paucity of applicable studies done with reasonable calorie levels and adequate protein. In essence, the definitive studies, which would apply to the calorie and protein recommendations being made in this book, have not been done. It is this author's opinion that a variety of dietary approaches can be effective...

Body composition issues

The primary selling point of the ketogenic diet is that it causes greater fat loss while sparing protein losses. As discussed previously, this stance cannot be unequivocally defended based on the data available. Anecdotally, many individuals find that fat loss is more effective and that less muscle is lost with a ketogenic diet compared to more traditional dieting. This especially applies to bodybuilders, who may be starting with far more muscle and less bodyfat, than the average dieter. However this is not reported universally and most likely reflects differences in individual physiology, insulin sensitivity, and other factors. Additionally, many dieters are drawn to the ketogenic diet due to the rapid initial weight loss which occurs from water loss. This is a double-edged sword. On the one hand, a rapid initial drop in bodyweight can be psychologically very encouraging for individuals who have battled with weight loss. By the same token, the rapid weight gain which can occur with...

Section 2 Choosing a diet

Three related but distinct dietary approaches are described in previous chapters. These are the standard ketogenic diet (SKD), the targeted ketogenic diet (TKD), and the cyclical ketogenic diet (CKD). Although it is not this book's goal to suggest that dieters choose a ketogenic diet over another dietary approach, a question which does arise is which of the three ketogenic diets is appropriate for a given individual. The major determinants of which diet is the best choice for any given individual are the amount and type of exercise being done, as well as some certain health related issues. The CKD alternates periods of ketosis with periods of high carbohydrate eating. Due to the structure of the CKD, it is critical to fully deplete muscle glycogen between carb-up periods. For individuals wishing to use a 7 day cycle (5-6 days of ketosis, 1-2 days of carbohydrates), this necessitates a fairly high volume and intensity of training. This makes the 7-day CKD most appropriate for fairly...

Coronary artery diseasehigh cholesterol

The impact of a ketogenic diet on blood cholesterol is discussed in detail in chapter 7. For many individuals, the ketogenic diet causes an improvement in blood lipid levels, especially in cases where bodyfat is lost. However, this is not a universal finding. Individuals with diagnosed coronary artery disease or high blood cholesterol must monitor their blood lipid levels for negative changes. Individuals who show negative changes can try decreasing saturated fat intake, while increasing unsaturated fat. Additionally, a fiber supplement may be helpful. If blood cholesterol levels continue to respond negatively, the ketogenic diet should be abandoned.

Section 2 Muscle Fiber Recruitment

Utilization of different fiber types (due to differences in physical characteristic) greatly affects the fuel used, the adaptations seen to training, and the effects of a ketogenic diet. All of the information which follows regarding exercise types and the necessity of carbohydrates or not is ultimately tied into the issue of recruitment.

An overview of fat and carbohydrate regulation

The increase in glycogen utilization at higher intensities is related to a number of factors including greater adrenaline release (1,15), decreased availability of FFA (16), and greater recruitment of Type II muscle fibers (15,17,18). The ketogenic diet shifts the crossover (i.e. lactate threshold) point to higher training intensities (15) as does regular endurance training (1,5). As discussed further below, this means that endurance athletes are able to maintain higher exercise intensities while relying on FFA for energy.

Section 3 The hormonal response to aerobic exercise

Several hormones are affected by aerobic exercise depending on exercise intensity and duration. Overall, the hormonal response to aerobic exercise is very similar to what is seen during a ketogenic diet. Levels of anabolic hormones, such as insulin, go down while levels of

Endurance exercise below 85 of maximum heart rate

At low exercise intensities, fat is the main fuel for exercise. As intensity increases, muscle glycogen plays a greater role in energy production. This has led researchers to examine the effects of both short-term and long-term carbohydrate depletion on endurance performance.

Section 4 Fatigue and weight training

As discussed in chapter 18, the impact of a total lack of carbohydrates on endurance training is very consistent performance is maintained or improved at low intensities (below 75 of maximum heart rate) but decreased at higher intensities (75-85 of maximum heart rate or approximately the lactate threshold). However, the effects of a ketogenic diet on weight training are not as well established.

Other causes of fatigue

Finally, there are possible non-metabolic causes of fatigue. During muscular contraction, signals are sent from the brain to the muscle, eventually reaching the muscle fibers through a structure called the sarcoplasmic reticulum (SR). Normal SR function may be impaired during exercise and this impairment may be related to a loss of intracellular potassium (71,104,105). Muscle potassium levels are decreased on a ketogenic diet as a result of glycogen depletion (104) further implicating glycogen depletion as one source of fatigue on a ketogenic diet. Additionally a glycogen-SR complex has been proposed (106) such that depletion of glycogen may physically impair conduction of signals to the muscle. Finally, the intracellular dehydration seen with a ketogenic diet may also affect strength levels (52,104,107,108).

Isoopus Errata Part Vi

We don't honestly know the long term effects of the diet. The longest any study has examined someone on a ketogenic diet is about a year (epileptic children are freguently kept on the diet for up to 3 years but they aren't a great model for dieting bodybuilders). Most health problems (i.e. heart disease) take years to show up.

Section 2 Aerobics and the precontest bodybuilder

Bodybuilders have typically performed their aerobic training at one of two times first thing in the morning on an empty stomach, or immediately after training. The rationale for this was that the lowered blood glucose and insulin would allow for better FFA utilization. Whether this strategy will have a benefit on a ketogenic diet is unclear. The nature of the ketogenic diet is that the body is relying on fat for fuel all day so it shouldn't make a difference whether cardio is performed prior to eating or not. However, morning cardio is a tried and true method for pre-contest fat loss, and may be a strategy worth trying, especially coupled with the herbal supplement yohimbe (see chapter 31). In theory, performing aerobics on an empty stomach first thing in the morning will maximize utilization of body fat, rather than using dietary fat.

Basic multivitaminmineral

Any calorically restricted diet may not provide for all nutritional requirements and the limited number of food available on a ketogenic diet may cause deficiencies as discussed in chapter 7 (1). At the very least, individuals on a ketogenic diet should take some form of sugar free vitamin and mineral supplement to ensure nutritional adequacy. Additionally, supplemental sodium, magnesium and potassium may be necessary, as detailed in chapter 7. Depending on dairy intake, a calcium supplement may also be necessary.

Other mass gaining supplements

Along with this, individuals constantly want to know if a given supplement will work on a ketogenic diet, or how it will affect ketosis. In all of these cases, there is simply no data available, and individuals will have to experiment to find what does and does not affect the diet.

Partial glycemic index

The glycemic index (GI) is a measure of how much a given carbohydrate food will affect blood glucose and insulin. Its primary use for ketogenic dieters is to pick carbohydrate sources while on a low-carbohydrate diet (where low GI carbs should be consumed) and also to make carb choices during the carb-up or around exercise (where high GI carbs are traditionally used). The following list uses white bread as a reference (given a value of 100) but some lists use glucose as the reference. To convert from the white bread GI to the glucose GI, divide by 0.7. To convert from the glucose GI to the white bread GI, multiply by 1.42. For ease of reference, foods are grouped by their GI, rather than by category. Therefore if individuals are looking for relatively higher or lower GI foods, it should be easier to make food choices.

Blood pH and ketoacidosis

A major concern that frequently arises with regards to ketogenic diets is related to the slight acidification caused by the accumulation of ketone bodies in the bloodstream. Normal blood pH is 7.4 and this will drop slightly during the initial stages of ketosis. There is frequent confusion between the dietary ketosis seen during a ketogenic diet and the pathological and potentially fatal state of diabetic ketoacidosis (DKA). DKA occurs only in Type I diabetes, a disease characterized by a defect in the pancreas, whereby insulin cannot be produced. Type I diabetics must take insulin injections to maintain normal blood glucose levels. In diabetics who are without insulin for some time, a state that is similar to dietary ketosis begins to develop but with several differences.

The ECA stack and yohimbe

The ECA stack is quite potent as an appetite suppressant in and of itself, especially when it is first used (9). Typically any anorectic effects of ECA go away within a few weeks of use. However, animal research suggests that combining ECA with the amino acid L-tyrosine may maintain the appetite blunting effect of ECA for longer periods of time (22). Individuals who find it hard to control their hunger on a ketogenic diet, may want to consider this combination. Yohimbe may also suppress appetite (2).

Exercise with verylowcalorie diets less than 800 calories per day

In severe dieting situations, aerobic exercise may actually be worse than just dieting (health benefits excepted). In one study, the addition of aerobic exercise (27 hours total over 5 weeks) to a very-low-calorie ketogenic diet (500 cal day) caused a greater drop in metabolic rate than dieting alone and caused no additional weight or fat loss (29). It appeared that the body compensated for the aerobic exercise by slowing metabolic rate at other times of the day.

Hypothyroidism and euthyroid stress syndrome ESS

The decrease in T3 due to hypothyroidism must be contrasted to the decrease seen during dieting or carbohydrate restriction. Low levels of T3 with normal levels of T4 and TSH (as seen in ketogenic dieting) is known clinically as euthyroid stress syndrome (ESS) and is not associated with the metabolic derangements seen in hypothyroidism (1). The drop in T3 does not appear to be linked to a drop in metabolic rate during a ketogenic diet (17,52). As with other hormones in the body (for example insulin), the decrease in circulating T3 levels may be compensated for by an increase in receptor activity and or number (1). This has been shown to occur in mononuclear blood cells but has not been studied in human muscle or fat cells (53). So while T3 does go down on a ketogenic diet, this does not appear to be the reason for a decrease in metabolic rate.

Highintensity aerobics and interval training

For most individuals (excepting pre-contest bodybuilders who are addressed separately in chapter 30), the primary goal of aerobic exercise should be on total caloric expenditure. For individuals with limited time, maximizing calorie expenditure by working at the highest intensity that can be maintained safely, and is compatible with a ketogenic diet, is the best choice. The inclusion of interval training from time to time can raise fitness level and increase fat loss. Specific guidelines for when and how to incorporate training techniques such as intervals are discussed in chapter 25.

Section 5 Other dietary effects on ketosis

Neither of these ideas have been studied directly. When the ketogenic diet is used to treat epilepsy, fluids of all types are restricted in an attempt to keep blood ketone concentrations very high, as high ketone body levels are thought to be part of the mechanism by which the diet works. This suggests that a high water intake might dilute blood ketone levels and prevent the rise in insulin which can occur. From a purely health standpoint, a high water intake is necessary on a ketogenic diet due to the dehydrating effects of ketosis. Some of the side effects which occur in epileptic children (i.e. kidney stones) may be related to the dehydration which is imposed and individuals are suggested to keep water intake high as a general rule. Although alcohol intake has been discussed briefly in previous sections, its effects on ketosis need to be discussed here, especially since many individuals want to know if alcohol is allowed on a ketogenic diet. In general, once ketosis is established...

Section 2 Recommendations for ending a SKD or TKD

There are few practical recommendations for ending a ketogenic diet in the literature. In research studies of the protein sparing modified fast (PSMF), carbohydrates are typically reintroduced slowly to minimize weight gain and gastric upset, which occurs in some people. Ending a SKD or TKD can be done in one of two fashions. If an individual no longer wishes fat loss, but chooses to stay on the SKD TKD, fat intake can be increased (to raise calories to a maintenance level of approximately 15-16 calories pound) until fat loss stops. Individuals concerned with rapid weight regain when they end a ketogenic diet should simply introduce carbohydrates slowly, perhaps adding twenty to thirty grams per day at most. To avoid possible problems with rebound hypoglycemia, primarily vegetables should be consumed with starches (pasta, rice, breads) remaining limited. Many individuals who turn to ketogenic diets to lose bodyfat tend to have problems with excessive carbohydrate consumption in the...

Gender Differences in fuel metabolism

There are differences between men and women in terms of the physiological response to aerobic exercise. While the exact implication of these differences are unclear, they have one major consequence with regards to the ketogenic diet, especially the CKD. At any aerobic intensity, women use more fat and less carbohydrate and protein during exercise (42-45). Studies also show that women do not respond to carb loading the same as men do, most likely because they deplete less muscle glycogen less during aerobic exercise (42). This has two important ramifications for women wishing to follow a ketogenic diet. First and foremost, less dietary protein is required during the week as less protein is used during exercise and at rest (43). As discussed in chapter 9, if ketosis can not be established and all other facets of the diet are in order, protein should be reduced gradually until trace ketosis is established. Additionally, since less glycogen is depleted during aerobic exercise (42,44)...

Section 3 Setting calorie levels

Calories and the Atkins diet a misconception A misconception, and commonly heard criticism, surrounding the Atkins diet is the (apparent) claim that fat can be lost with an 'unrestricted caloric intake', which contradicts basic thermodynamics (8). Strictly speaking, Atkins claimed that one could lose weight eating as much fat and protein 'as they liked' meaning they could eat until they were full without worrying about counting calories. carbohydrate but with 'unlimited' fat and protein will tend to automatically restrict calories. The mechanism behind the appetite suppressing effect of ketogenic diets is addressed in more detail in chapter 7. Studies examining the ketogenic diet at maintenance calories show no weight loss other than the small water loss seen with carbohydrate restriction. Simply put, there is no magical effect of ketosis that allows one to lose weight without some type of shift in energy balance that leads to either an increased caloric expenditure or a decreased...

Protein losses and nitrogen balance

There are many methods of measuring protein losses during dieting and starvation (7). Without exception all make assumptions and simplifications. From the standpoint of the ketogenic diet, some methods are better than others, but none are perfect. Many early ketogenic diet studies simply subtracted muscle loss from total weight loss and assumed the difference represented fat loss. The problem with this method was that assessment of muscle loss can be seriously affected by the glycogen loss seen on a ketogenic diet (8).

How much protein is needed to prevent nitrogen loss

In a second maintenance calorie diet study, subjects received 1.75 g protein kg ideal body weight daily (17). Nitrogen balance was attained in most subjects by the second week of the study. However, since the study did not list how many grams of protein were given to each subject, it is impossible to determine how much additional protein would have been needed to establish nitrogen balance from the first day. This study simply supports the idea that nitrogen balance can be attained quickly on a ketogenic diet, provided that sufficient protein is consumed protein for 9 weeks (18). Carbohydrate intake varied from 104 grams to 60 grams to 30 grams. Although all three groups were in ketosis to some degree (especially during the first three weeks), we will only consider that 30 and 60 carbohydrate gram diets as truly ketogenic diets. In a third study, which examined the metabolic effects of a variety of different dietary approaches, subjects were studied under a total of 6 different...

General Dieting Principles

Before discussing the details of the ketogenic diet, it is necessary to first discuss some general concepts which relate to body composition, metabolic rate, dieting, and fat loss. Most dieters tend to focus on bodyweight as the only measure of a diet's effectiveness. This is an incomplete approach and may be partly responsible for the failure of many mainstream weight loss approaches. Simply put, changes in bodyweight do not tell the entire story during a diet. Rather the prospective dieter needs to change focus to look at body composition the ratio of body fat to total body weight.

Understanding The Problems

Their exact name is alpha-2 adrenoceptors. (More precisely there are several kinds of alphn-2 adrenoceptors. On the fat cells, only alphn-2a subtype can be found but we will refer to them as alpha-2 receptors for simplification*. They arc not the first line of defense for our fat cells. The first line of defense among the bad receptors are insulin receptors. But once you go on a low calorie diet, especially the BodyOpus diet, your insulin level will go down. There will not be enough of th3t hormone to prevent fat cells from shrinking. Once the body realizes its first line of defense is out of order, it calls upon the second line of defense it increases the responsiveness of each alpha-2 receptor. From a dieters point of view, this means he will then be unable to lose fat where a high density of alpha-2 receptors can be found.

Table 5 Sample workout week for a volleyball player appears below

Of all the types of exercise, low-intensity endurance exercise can be sustained by a ketogenic diet. Individuals who are involved in endurance activities can therefore use a ketogenic diet during their training. It should be recalled from chapter 18 that high-intensity aerobic exercise above the lactate threshold can not be optimally sustained without carbohydrates. As well, most individuals find that their overall performance is higher on a carb-based diet. 1. A standard ketogenic diet (SKD) can only sustain exercise intensities of 75 maximum heart rate and below. Endurance athletes in their off-season, performing primarily long duration, low-intensity training may benefit from the SKD.

Section 4 Fatigue during aerobic exercise

The cause of fatigue during aerobic exercise depends on the intensity and duration of activity. This has implications for the effects of a ketogenic diet and each intensity of exercise is discussed. During low-intensity exercise (65 maximum heart rate and below), only Type I muscle fibers are recruited (51). Type I fibers have a high oxidative capacity and use mainly fat for fuel (13). Additionally, Type I fibers do not generate much lactic acid. The majority of energy during exercise at this intensity comes from the oxidation of FFA with a small contribution from blood glucose. As there is essentially an unlimited amount of bodyfat to provide energy, fatigue during this type of exercise is caused by dehydration, boredom and hypoglycemia (22,52). A ketogenic diet would not be expected to affect exercise of this intensity. Another possible source of fatigue during exercise of this type of the buildup of ammonia in the bloodstream (55). As shown in figure 2 above, ammonia is generated...

The basics of fuel utilization

Although this chapter does not discuss the ketogenic diet in great detail, the information presented is helpful in understanding the following chapters. There are four primary fuels which can be used in the human body glucose, protein, free fatty acids, and ketones. These fuels are stored in varying proportions in the body. Overall, the primary form of stored fuel is triglyceride, stored in adipose tissue. Glucose and protein make up secondary sources. These fuels are used in varying proportions depending on the metabolic state of the body.

Anabolism and muscle growth

The catabolic effect of the ketogenic diet has been discussed in detail in chapter 5 and are not repeated here. Although anabolism is discussed in greater detail in chapter 20, a few general comments about anabolism and muscle growth are necessary. The exact mechanisms behind muscle growth are not well understood at this time. In general, it can be said that net muscle growth requires that protein synthesis be greater than protein breakdown. This assumes that a stimulus to synthesize new proteins (such as weight training) has been applied to the body.

Why the discrepancy between short and longterm studies

As noted, there is a discrepancy in the capacity for endurance performance between studies of short-term (1-5 day) glycogen depletion compared to longer term (2-6 weeks) adaptation to a ketogenic diet. It appears, as with many aspects of human adaptation, the impact on skeletal muscle metabolism of a ketogenic diet may take several weeks or more to occur (58). Thus during the first few 3-4 weeks of a ketogenic or CKD, aerobic exercise performance will most likely decrease. With chronic carbohydrate depletion, the muscles adapt by improving their ability to use fat for fuel and performance may improve again.

Section 2 Nitrogen sparing A theoretical approach

After much research, it was concluded that a protein intake of 1.5-1.75 grams protein per kilogram of ideal body weight (ideal body weight was used to approximate lean body mass) would spare most of the nitrogen loss, especially as ketosis developed and the body's glucose requirements decreased. As we shall see below, providing sufficient protein from the first day of a low-carbohydrate diet should prevent any net nitrogen loss from the body. Of all aspects of the PSMF or ketogenic diet, adequate dietary protein is absolutely critical to the success of the diet in maximizing fat loss and sparing body protein. The ketogenic diet as most consider it is simply a PSMF with added dietary fat. Note that the addition of dietary fat does not affect the adaptations or protein sparing effects of the PSMF. Only overall fat loss is affected since dietary fat is used to provide energy instead of bodyfat.

Option 1 Stay on the CKD

The major changes which must be made for those who want to stay on a CKD are in calorie levels, length of the carb-up, and training strategies. As discussed in chapter 3, gains in lean body mass may require a caloric intake of 18 calories per pound of bodyweight or more. Some individuals find consuming this many calories on a low-carbohydrate diet to be difficult. As well, since protein must still be somewhat limited to maintain ketosis, this means that fat intake must be raised to high levels. The potential health consequences of such a dietary strategy are unknown. To reiterate, without long term data on the health consequences of a SKD or CKD, it is not recommended that the CKD be followed indefinitely.

Section 2 Glycogen depletion during weight training

Since high-intensity activity such as weight training can only use carbohydrate as fuel, a SKD will not be able to sustain high-intensity exercise performance. This mandates that carbohydrate be introduced into the SKD without disrupting the effects of ketosis. The two primary ways to introduce carbohydrate to the SKD are the CKD, which allows a period of high carbohydrate consumption lasting from 24-48 hours every week, or the TKD where the dieter consumes carbohydrates around training.

Which tissues use glucose

This peculiarity of brain metabolism has led to probably the most important misconception regarding the ketogenic diet. A commonly heard statement is that the brain can only use glucose for fuel but this is only conditionally true. It has been known for over 30 years that, once ketosis has been established for a few days, the brain will derive more and more of its fuel requirements from ketones, finally deriving over half of its energy needs from ketones with the remainder coming from glucose (6,26,27). As a few tissues do continue to use glucose for fuel, and since the brain's glucose requirement never drops to zero, there will still be a small glucose requirement on a ketogenic diet. This raises the question of how much glucose is required by the body and whether or not this amount can be provided on a diet completely devoid of carbohydrate.

Figure 1 The ketogenic ratio

The ketogenic diet mechanism of anticonvulsant action. Adv Neurol (1980) 7 635-642. For the treatment of epilepsy, the ratio of K to AK must be at least 1.5 for a meal to be considered ketogenic (1). Typically, this results in a diet containing 4 grams of fat for each gram of protein and carbohydrate, called a 4 1 diet. More details on the development of ketogenic diets for epilepsy can be found in the references, as they are beyond the scope of this book. Although this ratio is critically important for the implementation of the ketogenic diet in clinical settings, we see in chapter 9 that it is not as important for the general dieting public. Each macronutrient is now briefly discussed within the context of the equation in figure 1.

Table of contents

Introduction to the ketogenic diet 11 2. History of the ketogenic diet 13 Part II The physiology of ketosis 7. Other effects of the ketogenic diet 71 Part III The diets 9. The standard ketogenic diet (SKD) 10. Carbs and the ketogenic diet 11. The targeted ketogenic diet (TKD) 12. The cyclical ketogenic diet (CKD) Part IV Other topics 14. Ending a ketogenic diet 15. Tools for the ketogenic diet

Isoopus Errata

As discussed last issue, during calorie restricted diets, many individuals experience a drop in active T3 levels in the bloodstream while Thyroid Stimulating Honnone (TSHi and T4 levels remain normal. This is referred to as Euthyroid Stress Syndrome (ESS) and can be roughly tracked by changes in morning body temperature while dieting. ESS is known to occur in humans under such conditions as diabetes mellitus, glucocorticoid therapy, calorically restricted or ketogenic diets, and fasting.1 From kinetic tracer studies, it has been inferred that part of the reduction in active T3 honnone is caused by a decrease in the enzyme 5'-deio-dinase which converts inactive T4 to active T3. This is thought to be a survival mechanism to prevent too great a loss of body fat and muscle Also, with lowered T3 levels, metabolic rate decreases which may cause a fat loss plateau to occur.

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