Me & My Ketogenic Diet
This picture is me at age 29 finishing 4th in the Dipsea in Mill Valley, CA. The Dipsea is the oldest trail race in the US. It’s a “handicapped race” meaning the better you are, the later you are allowed to start. I ran this race only months after finishing 16th in the 1976 Boston Marathon (BAA) in 2:29:38. The 1976 BAA was the “Run for the Hoses” when the temperature at the start was 100 degrees F, by some measures. I could run that fast and handle the heat because I was 5 ft 6 in and 130 pounds. I am very thin boned so that weight was not excessively low for me. At that time, I almost never ran a 26.2 mile marathon slower than 2 hours and 30 minutes. Those were the days! I trained only about 80 miles a week, far fewer mile than the 100 miles per week you need to be reasonably good, but I was a medical student, medical resident, cardiology fellow, and young cardiac attending… you hear the whining?.
Fast forward to my early 50’s and I was still running some and weighed about 140, but at age 64, I broke my right hip. I did it on the BAA course before the 2012 race. The story is that I was turning 65. I had always done pretty well in my age group, but wanted to train really hard for the next year and do really well. I planned to beat up on those 66–69 year olds before they escaped to the 70+ brackets. I needed to cure a right hamstring tendonosis so I had decided to take a year off from the BAA to help it heal even though I had a streak of 15 straight BAAs going. My son-in-law knew I was bummed not running the race so suggested that we borrow bikes and ride the course together the morning of the race, early, before the course was closed. The bike he borrowed was big for me, and I am not sure exactly what happened but I think I caught a pedal turning and took a bad tumble. I needed a total hip replacement, and was told by my orthopedist that I could “only run from fires”. I gave up running.
After that my weight went straight to 160+ lbs and I could not get it down. I do not have great self-control anyway, especially with food. I have usually followed the “see food diet”; I see food and eat it. I did continue to go to the gym daily, doing weights and floor exercises. I continued to ride my bike, often to/from work, a pretty flat 16 miles each way. But without the running miles and with the food, I stayed what was heavy for me.
This last December I saw myself sideways in a mirror and was shocked. I looked about 24 weeks pregnant. I assure you I was not pregnant for two good reasons, but I will leave those reasons to your imagination. One of the reasons is NOT that I had a vasectomy. I decided then and there I was going to lose weight.
Many of my patients rave about the ketogenic diet, so that is what I did. I eliminated any carbohydrate I could think of: bread, pasta, potatoes, sweet drinks, fruit and fruit juices since both have a lot of sugar, that’s why we like them. I avoided root vegetables like beets (they are related to sugar beets) and parsnips since they taste too good not to have carbohydrates. I eat only fatty stuff, fish and meat. For desert I have nuts and cheese. I eat a lot of almonds, but with some caution because almonds are among the highest nuts in oxalate content, and I have one physician friend in his 60’s who developed his first kidney stone, an oxalate stone, eating tons of almonds.
I started this diet on December 31, 2020 weighing 162 lbs and the results were very interesting. The first 2 days I was hungry, not terribly hungry, but I had to think not to eat. I dropped several pounds quickly in the first 3 days. This was almost certainly fluid weight. Each gram of muscle glycogen is stored with 3g of water (1) so I suspect the elimination of carbohydrates drove glycogen breakdown which mobilized intramuscular water. My weight has dropped progressively over the 2+ months of this therapeutic experiment and as this is written on March 10, 2020, I am at 145.5 lbs. My goal is 145 lbs. I have not tested for ketones, ever. I continue to go the gym daily , but have always done that so the weight loss is due to the diet and not exercise.
My daily approach is to have a very large coffee for breakfast with about 25% of the cup half and half That’s it, that’s breakfast. At lunch I repeat breakfast. For dinner I start with a whole bag of prepared salad, the ones you can buy at the grocery store. One I like has some sweetened cranberries in the dressing, and I do eat those. I then have whatever meat I can get. I guess eating only the evening meal is “intermittent fasting”. The New England Journal of Medicine just had a review on fasting and intermittent fasting and emphasized that our genes were not developed for 3 squares a day.(1) Our ancestors ate and then fasted until they killed another woolly mammoth.
I weigh myself on the clinic scale first thing everyday and write it down on a sheet on the side of my bookcase. The weight loss pattern has been interesting as shown by the following graph. I will be relatively stable for several days, and then a big drop,. Then I will bounce back almost to the prior plateau for several days and then drop again. The graph shows that this has happened repetitively. It is not due to intestinal function.
I blogged earlier (30 Apr2019- https://medium.com/@pauldthompsonmd) that blood lipid levels fall when a person is losing weight, despite the high fat/protein intake. There are anecdotal reports, however, of some people getting profoundly hyperlipidemic, either with increased cholesterol ( C ) or increased triglycerides (TGs). I think these folks may be eating too little and getting the hyperlipidemia of early starvation. The mechanisms are not absolutely clear. William Connor, one of the greats of the lipid field, reported in 1975 using rabbits and radioactive tracers that the increased C was due to mobilization of C from the fat droplets in fat cells. (2) The hypertriglyceridemia that occurs in some patients I think occurs because fat cells are releasing free fatty acids (FFA), which go to the liver and generate TGs. I suspect those who get the hyperTGs are more insulin resistant, but cannot document that. Insulin keeps fat in fat cells so if you are insulin resistant, the FFAs are more likely to come out and become TGs. Caloric restriction is necessary to keep losing weight but not so much so rapidly that C or TG levels go way up. Just to be sure, however, I checked my blood levels 8 weeks into this. I take atorvastatin 40 plus ezetimibe 10 every other day so my baseline LDL was low at 74, but fell further to 54 mg/dl despite the high fat diet. My hemoglobin a1c was borderline at 5.9 at the start, and fell to 5.6, again at 8 weeks. It will go lower because the lifespan of a red cell is about 16 weeks so changes in glucose take about 4 months to be maximally demonstrated by the a1c.
The amazing thing to me is that I, Mr. No-Diet-Self-Control, have not been hungry. The ketones really do suppress hunger. I almost have to remind myself most days…not all days…to eat dinner. That also makes sense. Evolution gave a survival advantage to those who could be in caloric deficit, and yet not too miserable to go hunting to cure the problem or so hungry for food that they became reckless hunters!
Honestly, my experience with this had made me think that no one really needs to be overweight. If they can get through the first several days of hunger, knowing that the ketosis will take that hunger away, then it all gets quite tolerable.
Now the disclaimer: I am a simple cardiologist. Talk this idea over with your clinician. Check your lipids after 4–8 weeks to make sure they are OK. Don’t go almond crazy because they may give you an oxolate stone. But try it, you might like it.
These are also my personal observations on me. They are not clinical recommendations for individual patients. Check stuff out with your own clinician. In other words, reader beware.
1. Fernandez-Elias VE, Ortega JF, Nelson RK, Mora-Rodriguez R. Relationship between muscle water and glycogen recovery after prolonged exercise in the heat in humans. Eur J Appl Physiol. 2015;115(9):1919–1926. doi: 10.1007/s00421–015–3175-z [doi].
2. Swaner JC, Connor WE. Hypercholesterolemia of total starvation: Its mechanism via tissue mobilization of cholesterol. Am J Physiol. 1975;229(2):365–369. doi: 10.1152/ajplegacy.1975.229.2.365 [doi].
