Many folks, when following a keto or low-carb type of diet, are following the net-carb method. What are your thoughts?
Well, it can work for some people, but it doesn’t necessarily work for everyone. There’s a stricter, stronger way to do things. It’s called total carbs. There’s no right or wrong; you just have to understand what net carbs means. It means you’re allowing more carbohydrates in the diet for the day, because when you do net carbs, you subtract out the fibers, thinking that the fiber doesn’t impact on the metabolism, although it can. Even non-absorbable fiber can be absorbed. The naming of these things doesn’t reflect the reality of what happens metabolically. Some people do subtract out the sugar alcohols and other non-sugar sweeteners and then that becomes the net carbs. So, a bar that has 20 total carbs, you subtract out the fiber and sugar alcohols and on the label it has 2 net carbs. That’s the other thing that doing net carbs does: it makes you think it’s okay to have these extra products that sometimes have a lot of total carbs, so it can mess people up. It’s not quite as strong as using total cabs, the net carb method, and it can trip people up. For example, this week I asked someone why things weren’t working as well and it took some detective work to figure out that this person was starting to use these bars that had 20 to 30 carbs in them. The net carbs method also can make you think you can have these ice creams that are available that are not truly low in carbs.
It’s not wrong; it’s just not as strong as total carbs. So, don’t bail out if you’ve done net carbs and it’s not working. You might want to consider shifting over to the total carb method. It’s kind of like going from over-the-counter medicine to a prescription strength medicine. Net carbs is like over-the-counter medicine that’ll work for a lot of people, but if you want the prescription strength, use the total carb method.
There’s a fortune of keto cookbooks and wonderful recipes and people are making cheesecakes and all sorts of desserts. They’re using ingredients like coconut or almond flour, but the fact is they really are eating a lot of carbs.
Yes. And, I’m sorry, it’s not fair, but some people can eat more carbs and it can work – I think that one of the great flexibilities or robustness of a low-carb diet. Be a careful consumer of who’s telling you what to do. Who wrote the cookbook? Who has the YouTube channel where the information is coming from? If they’re young, they probably can eat more carbs. If you’re older than the person who’s teaching you, you want to just be a little careful. If you’re not as active or if you’re taking medicines and these people giving you information aren’t on medications, those are all things that can allow them to eat more carbs and still have the metabolic results that they want and that you want, but you’re not able to add in the almond flour, coconut flour, the bars and other things that you’ll see out there.
That’s the other thing that you’re seeing now – people getting tripped up by the “keto” label. There’s no certification of “keto.” Maybe we ought to have an Adapt certification, where it really is keto certified! Make sure you always look at the total carbs on the label. We teach that in all of our classes and information. Net carbs is not wrong or evil, but it can trip people up.
What’s nice is that some people can have these products and can make their own. A good friend of ours, Kristie Sullivan, has a line of cookbooks where she goes to great lengths to recreate her favorite desserts that she had when she was young. If you do that every day though, that’s not going to be so good. Some people will use those and get tripped up in my clinic, because they can’t have that amount of carbs yet. I guess it’s nuanced. Just understand that there’s more to the whole low-carb keto world than using net carbs.
Another big mistake and also quite a contentious topic is that people overdo the fat.
Right. One of the common mistakes, which has been there for a long time, has been the over-consumption of zero-carb foods, but they have a lot of calories. The teaching that we do blends a carb restriction and calorie restriction and the same kind of approach. I had someone recently who was an engineer and couldn’t figure out the principles, because we blend the calorie restriction – meaning fat restriction – and the carb restriction in our approach. That means you have to limit the cheese, you have to limit the oils and cream and mayonnaise. People come in and say, “But doc, it’s zero carbs.” Well, I know, but you can over-consume the energy, over-consume fat. I know, cheese tastes great! If you love eating food, which many of us do, you can have great food but you have to still keep an eye on the amount. Limit the amount of the high-calorie foods like cream, cheese, oils, butter in coffee, MCTs. MCT oil – medium chain triglyceride – is something new. It’s a keto phenomenon that raises the blood ketone levels, but it hasn’t been around in the weight loss world, never been studied in a weight loss diet that I’m aware of, so be careful about adding drinks that have oils and butters and things like that. You can have cream, and I think you should have cream, because it’s so tasty, but you have to limit the amount over the course of the day.
I wanted to add on what you said earlier in terms of the calorie restriction approach. Most people are going to hear that and think, “Oh my word, this is another diet where I’m going to be starving!” I know that’s not the case. That’s because people do it and feel satiated.
Right. We don’t count calories when we teach this. For most people, this automatically becomes a low-calorie diet, because the hunger goes down so much. You eat less within a day or two. The hunger goes away in a day or two, the weight comes off at one to two pounds per week, which of course is never fast enough for people! The idea is that it is a low-calorie diet, but you don’t have to count calories. I don’t want to make people afraid of that. I would say that 95 out of 100 times, there’s an automatic reduction in what people eat. So, that’s why this is known as a weight loss diet.
And without being hungry, right?
That’s an important point. One of the features that sets a lo-carb keto approach apart from all of the other low-calorie, higher carb approaches is that there’s no hunger. There are approaches where you can fool the body with fibers and all these different things, where you can reduce hunger as well, that’s fine. Maybe I should say that this is one of several approaches where you can lose weight without hunger at all, which is pretty amazing. I’ve even seen people today who are 70 years old and they’ve never tried a low-carb or keto diet. They’ve only tried approaches that had hunger. They may have even had weight loss surgery, maybe even had it a couple of times and no one ever explained to them how they could lose weight on a low-carb diet without hunger. And they’re surprised when they’re 75 years old, that this was available all along.
Unfortunately sometimes you get quoted the wrong way. When you advocate people eating McDonalds, you show them what they can eat at McDonalds for minimal amounts of money. It’s not that you are advocating people should go eat at McDonalds; it’s that you can reverse a lot of these metabolic conditions if you simply cut the carbs.
That’s right. One of my teachers said, if you’re worried about what other people are going to say, don’t say anything, because they’re always going to mess it up.
You have to understand the approach of the person you’re listening to and learning from. My approach is to make something work in a clinical setting. Many people come to me as their doctor and they give me certain parameters of how they want to live and I can influence some of them. If someone has no money, I can’t give them money, so I have to work with the parameter. In Durham, North Carolina, one of the things I learned from my patients is that they figured out how to eat at fast food restaurants or even just any general restaurant and make it work. I don’t know the last time that I ate at McDonalds. I think it was when I was in South Africa with you, Glen. I think we went for kicks! But what I learned is that the most important factor is to just keep the carbs low. So, don’t eat the buns, don’t eat the french fries; they’re potatoes, they turn into sugar and raise the blood sugar and insulin. Don’t drink sugary sodas, and it can work just fine.
You’ll get advice from people who are trying to influence national policy for food distribution and food quality, or they might even have companies marketing their new high quality foods, which is great, but I can’t wait for that to influence everyone. I need this to work today. The saying is, “I need this to work Monday morning,” for people who show up in my office. While all of these things are great in the big picture, they’re not necessary and essential to have this work. When you have this information, it can work there. You change the message. I’ve met doctors who tell their patients, “Don’t eat fast food and you’ll lose weight,” but that doesn’t work. Doctors also say, “Just go exercise and eat less.” That doesn’t work without more guidance than that. I’m still holding out for the studies proving that grass-fed beef and grass-fed butter, while they’re very tasty and they seem to work better in the environmental, sustainable, agricultural way, I’m waiting for the human study that says there’s a better outcome. We know that food can be different in terms of composition, but the body processes food and takes the good and the bad and it’s still a bit of a stretch to say that we know that eating that way will give benefits beyond just cutting carbs and eating at other the other fast food places, not just McDonalds, we have Burger King, we have Wendy’s. It’s interesting, because some people are very strict about where they’ll go, so I’ll work with that. If you don’t have a program that accommodates that, you’re not going to be helping a lot of people, at least in my area.
Some people don’t eat enough salt when starting a keto diet…
This doesn’t happen for everyone, but there is a phenomenon called “keto flu,” where you don’t feel well for a few days. Most people don’t get it, so I don’t want you to be worried about starting something and having serious side effects, because most people don’t. There’s a metabolic change that happens when you take away the carbs. Carbs make your insulin level go up, and insulin makes your body hold onto salt. So, you might notice you’re walking around with puffy fingers and ankles – that’s the carbohydrate that’s causing it, because it’s making you hold onto extra salt.
So, in the first week or two, you might get rid of a lot of that salt by urinating a lot. This is a good effect, but it can also lead to fluid shifts, which we think is the main reason behind keto adaptation or keto flu. In our teaching, we’ll talk about adding some salt early on, to reduce your chances of getting these side-effects. Of course, in a clinical population, if someone’s on blood pressure medicine or they have a history of heart failure or liver failure or they’re on dialysis, they shouldn’t take extra salt. With those caveats, you want to add extra salt because your body is getting rid of it now. In the keto world, we tell people to eat fat and we tell people to have salt, and I know that most people have been told not to do those things for so long, but that’s the different metabolism that we’re teaching people to have. It’s not difficult – most foods taste better with more salt. If you’re on Food Network, doing a competition and you don’t add salt and pepper, you don’t win, you don’t even get close!
I even go so far as to say, listen to your body. This is a big part of the teaching. If you’re hungry, eat; if you’re not hungry, don’t eat. If you’re craving salt, have salt – of course, don’t go for salty chips or pretzels. The urge for salt is like thirst. It’s a signal that your body wants or needs it. These signals get messed up if you’re taking medications, like a fluid pill that gets rid of the salt and your body is trying to accommodate for that. So, we try to get people off medications as fast as we can, with monitoring of course.
Some medications have sugar in them. People can’t reach their goals and they’re confused as to why they’re not producing ketones, or why their blood sugar is high, or why they’re not reaching their goals.
Every year during the cold season in wintertime, I screen for sugary syrups, for cold remedies and for Flonase nasal spray, which is a steroid medicine that raises blood sugar and which can actually cause weight gain. These are the troubleshooting techniques that we use when things aren’t working well. You can always screen for whether you’re having those things or having too many carbs, by using a ketone detecting method – checking urine for urine ketones, or checking the blood. The way we teach people is that you want to be careful about every little thing that you’re consuming, whether it be a drink or those little Tic-Tacs come to mind, these little candies that, like medicines, can add up over time. Part of the process we have in a clinical setting is to have people bring in their vitamins and their supplements so we can look at them. I’ve had some people who are on ten different vitamins, different supplements, and each one of these little pills has one gram or half a gram of sugar in it – that adds up to 20 grams, just from vitamins and supplements. While most doctors might not think to ask about vitamins and supplements, I do. I worry about everything that you put in your mouth in terms of the carbs that are in there.
Rhonda asks: “I started measuring my ketone levels and it’s been three weeks and I’m still not producing ketones. Is this normal?”
It can actually be. The purpose of a keto diet is not to be “in ketosis” or to have urine, or blood, or breath ketones. The purpose of a keto diet is to achieve some sort of metabolic change so that you’re improving your health. Urine ketones were the first ones that were available (to measure at home); they had been available for a long time. We knew pretty early in our research that almost everyone develops ketones here, but not everyone. The time of day matters. There was a paper with a dozen people in it, where the best time to measure for urine ketones is in the evening or the early morning, like 3 a.m. So, by the time you get up at 6 or 8 a.m., they’re not there anymore. I recommend that people measure in the evening if you do want to measure. Urine ketones are probably enough.
In my clinic setting I say to people at first, “Don’t measure, don’t worry. I want to keep it simple.” If your hunger is gone, you’re losing weight, or losing inches, that’s the goal – your blood sugar is coming down, you’re getting off medications. The keto measurements can be very helpful, but they’re not essential. If you want to do it as quickly as possible, just stay very strictly to the food program and don’t worry so much about monitoring.
Bethany asks: “My friend and I started at the same time. In three months she’s lost close to 20 pounds; I’ve lost only 7. Our weight was about the same when we started and we are both the same age. Am I doing something wrong?”
The big-picture view is that it works differently in different people. Rate of weight loss is different. I see a range of 1-2 pounds per week, and in that range it’s probably a metabolic difference, or it could be that someone’s on medication, someone’s more active than the other person. In general, men lose faster than women, so you’ve just got to account for that. It’s okay. There’s individual variability. If you’re the 1 pound per week or the 2 pound per week, I tell people to just relax, it is working.
If you’re eating three meals a day and you’re eating out of habit, not hunger, I’ll start whittling away at that concept. “Time to eat” is not hunger, that’s the habit side of it. Some people from the get-go will understand that and then just eat one meal a day. The main factors that lead to weight loss are how much you eat – the energy input and the caloric intake – and then the metabolic rate of that given individual. Most of you in families may have a sibling who has the “fast metabolism,” they’re the ones who’ve exercised and they can eat anything and never gain weight, and then there’s the person – like me – who ate something and put it on, I don’t really have that urge to exercise all the time. So those metabolic differences can explain why there’s that variation.
Think about it this way: If you’re losing a pound per week and you’re doing it for a year, that’s 50 pounds. The range I see is from 50 to 100 pounds for a year. No pills, no products, no surgery…It’s just changing the food, which is pretty amazing.
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