Ground Rules

Your comments and questions are welcome.

If you are interested in the science and clinical experience related to low-carbohydrate ketogenic diets in general or the recent study I have done at Alert Bay on a traditional First Nations style of diet, please feel free to submit a comment or question.

Posts must be respectful of others and must remain on topic. Factual criticism is okay but personal attacks on individuals will not be tolerated. Posts that promote websites, books, commercial diet plans or products that I am not personally familiar with will not be published.

I look forward to an informative and enlightening discourse. I shall endeavour to respond to all inquiries.

15 thoughts on “Ground Rules

  1. My wife & I have read much about your research, and that of Drs. Phinney, Volek, Westman and others. As a physician, you may be interested to know that my wife’s father, a 90-year-old long-retired physician with Type II diabetes, switched to a very low carb diet in October 2011 and is very pleased with the results, including significantly reduced medication.
    For our part we have been on the diet for about a year, and have a few short questions if you have time to respond:
    1. Is there a way to find a physician locally (Edmonton) who is knowledgeable about low-carbohydrate diets?
    2. We’ve wondered why we’ve been unable to lose weight on the diet. Neither of us has a lot to lose, but 10 or 15 pounds would be appreciated! We are in our late 50’s, quite active, and quite strict with our carbohydrate intake. Would Doxepin as an insomnia aid negate the ability of the diet to help lose weight?
    3. We recently purchased a B-OHB monitor recommended by Phinney & Volek, & find our ketones generally at a lower level than we’d expected, & quite variable (over a period of two weeks, one of us had readings of 0.7, 1.8 & 0.4). We thought we were pretty strict & consistent with the diet. Any thoughts?
    Any help that you could give would be much appreciated! Thank you.

    Dr Jay’s Reply:

    I don’t know of a physician in Edmonton who is knowledgeable about low-carb diet, unfortunately. Doxepin is a tricyclic anti-depressant and weight gain is one of the possible side-effects of that class of drugs. Since you are not terribly overweight, it might very well be the factor that is making it hard to shed those few pounds. I know Volek and Phinney are recommending ketone testing but it is not something I have had experience with, yet, apart from the usual urinary dipstick testing. If you are eating too much protein and not enough fat, I suspect that could lead to lower ketone levels even though you are strictly avoiding carbs. Most often, though, the failure to get into ketosis is because there is some unsuspected source of carbs in the diet. Sorry I can’t be more helpful.

  2. Thank you for taking the time to reply to our inquiry. We will re-evaluate possible carb sources, and check our protein:fat intake. Thanks again.

  3. Hi Dr Jay,

    I have been reading quite a bit on the role of bacteria in the problem of obesity, and diabetes. A large study on bacteria was in the news, and how the bacteria adapted to their environment. Our diet can change in a short time the environment the bacteria live in. We will not need the same bacteria if our diet has little carbs.

    Also related, is the problem of antibiotics. After such treatment, the bacteria may never come back completely, and thus making it harder for us to digest and handle carbs.

    Have you looked into LC/HF in treatment of intense infections, and AIDS. You were in that field of AIDS management at one time. I have read that the reason AIDS is so rampant in Africa is because of lack of nourishment. Dr. Weston Price wrote that those people on their traditional diet, did not get Tuberculosis.

    Here are some links I found on bacteria, diet, and obesity.

    Thanks for all you do!

    Dr Jay’s Reply:

    I agree that there is something going on with gut flora. I’m just not sure which end of the chicken and egg puzzle applies. There was a fascinating study which took gut flora from obese rats and injected it into the guts of normal rats. The normal rats then became obese. That raises a whole host of questions to which I don’t have answers. Definitely something to consider, though. As my friend, Mary Vernon, says, “this ain’t rocket science, it’s more complicated than that”.

  4. I just finished reading The Art and Science of Low Carbohydrate Performance, and earlier this year I read Volek and Phinney’s first book. I’ve been on variations of a low-carb diet for eight years and read all the major books that have come along. I’m currently training for an Ironman and I started a ketogenic diet in January after reading Petter Attia’s blog. I did not supplement, however, and I started to develop constipation and night-time cramping. I’m particularly interested in the cramping issue as I’ve experienced debilitating leg cramps in a couple of marathons and while swimming. Volek and Phinney lay the blame on magnesium, but they offer no references for this claim (as opposed to the copious references for most of their other claims). When I do my own search of the academic literature I can find no papers that support this claim and some that dispute it.

    Do you know of any papers that address magnesium and EAMC?



    Dr Jay’s Reply:

    I have not seen literature on this. I believe there is something on the fact that Mg++ deficiency is common among people with metabolic syndrome and type 2 diabetes. I think this may one of those things that Steve Phinney figured out on his own or perhaps learned a long time ago in the course of getting his PhD in nutritional biochemistry. In my case, when he heard I was having night-time leg cramps he checked my reflexes. They were a little hyper which he said was diagnostic of Mg++ deficiency. The problem resolved when I started taking mag64. I think that, plus getting adequate salt, are the keys to avoiding muscle cramps on LCHF. Hope that helps.

  5. Well, I must say that since starting a one-a-day cal-mag pill I have not had any night-time cramps. I couldn’t find SlowMag or similar in Vancouver so I’m taking Webber Naturals (333mg calcium, 167mg magnesium, Krebs Cycle with D3).

    I’m still having problems with constipation, though, despite following their recommendations regarding increased sodium intake. I never used to have any problems at a 100g carb per day, but dropping below 40g per day brought on the trouble. Any ideas about that would be much appreciated.

    Dr Jay’s Reply:

    If you are getting enough salt, my guess would be that your gut is taking some time to adjust to a very low carb intake. I think that what we take for normal bowel function may actually not be normal but rather is the way the gut responds to carbs. When the carbs are sufficiently reduced, the gut takes some time to adjust and will eventually find the “new normal”. The role of gut microbes in this is intriguing and may turn out to be very important. In case it is, you might want to increase your intake of fermented foods to see if you can speed the colonization of your gut with healthier microbes. I don’t have evidence that this is what is happening but I like the theory in the Spreadbury paper and I am not aware of any downside to giving this a try.

  6. Hi Brian,
    I take 300 mg of calcium and magnesium citrate powder twice a day, as well as about a tsp and 1/2 of Celtic sea salt a day. As for constipation, I mostly had the diarrhea instead. Constipation can happen if you go low carb too soon without a lot of fat. For me, the coconut oil kept me from constipation. Do you take a lot of coconut oil? How much vitamin C do you get. It is known to loosen the stools(reaching a saturation). You may need a lot of C at the present. Hope this helps.

  7. Hi Dr. Wortman,
    I recently watched a program called “Programmed to Be Fat” on the Nature of Things. I discussed chemicals that we are exposed to and obesity. Dr. Paula Ballie-Hamilton wrote a book called, “Toxic Overload”. Which supports your theory of returning to the First Nations traditional diet. I also read the article from Dove Press, it seems to connect for me.

  8. Dr. Jay:
    You know who I am – and know that I am a major proponent of low-carb lifestyles for “curing” just about every ailment. However, it appears that my unfailing belief is being hugely challenged by a situation very close to me. I don’t know if you can help at all, and understand that giving medical advice on a blog is problematic, but we are desperate. I’m posting on all my favorite low-carb blogs, but feel like you might be our best hope. I’ve posted about all of this before, and you might remember some of this story, as I have done this in the past, starting over a year ago and got some suggestions. But after a year, the situation has gotten worse instead of better. My sister Jane was diagnosed as Type II (runs in the family – took the lives of our grandfather and father and all of us have carb intolerance) in 1999 after years of fighting weight issues with low-calorie, low-fat diets. She, my brother, and I all learned about low-carb diets about that time and all have pursued low-carb lifestyles. My sister persevered despite reluctance from her physician to use diet to manage her blood sugar. She took Metformin from the start and over the years has been on Januvia. She has declined other medications and refused to take insulin. Her blood sugars have remained above normal and she has tried all sorts of “tweakings” of her low-carb diet. Last summer she went to see Mary Vernon (we live fairly close to her Kansas office) and had no success. The only recommendation Dr. Vernon and her associates made was a low-carb diet and they just couldn’t understand that she’d been on a low-carb diet for 12 years! Jane also corresponded with Jackie Eberstein of the Atkins Society who suggested a yeast reducing diet, which Jane religiously followed. Not seeing great results, she, with my encouragement, has tried really upping her fat intake and lowering protein to replicate my ketogenic diet which I consider for me to be next to miraculous. Nevertheless, this past year, Jane’s fasting blood sugars have risen exponentially, and her readings since attempting to go ketogenic are consistently between 180 and 250. First morning readings are the highest and they drop throughout the day. However, her last A1C was 10. This is really alarming and we have no idea what she should do. (My partner, who is also having great results from a ketogenic diet, losing 40 pounds in the last few months, is a retired Family Physician, so he has tried to help her since her own doctor is not sympathetic to the idea of treating with diet and avoiding medications. His only idea is to get her off her beta blocker which she claims she can’t do without getting rapid heart palpatations and severe migraines.). Her doctor wants her to take Byetta and I’m sure will really start pushing insulin. Any ideas what is going on here? Thoughts about what she might do?

    Dr Jay’s Reply:

    I am familiar with you through your comments here and on other internet fora. Clearly, we share an appreciation of the benefits of LCHF and, particularly, what it offers to people who have developed insulin resistance. I like your accounts of what it has done for you and your husband. I think those stories are inspiring to others so I do appreciate seeing your comments on the various blogs, including mine.

    The situation with your sister is unfortunate. As I have indicated elsewhere, it is very difficult for me to offer specific recommendations rather than general advice and guidance. I cannot be seen to be practicing medicine via the web on people I have never seen. In your sister’s case, I am puzzled as to why she is unable to achieve significant weight loss or the other metabolic benefits of this type of diet. Usually, when that happens it means that carbs are somehow sneaking into the diet, perhaps innocently in a food type that is not recognized to be carb-laden or, in some cases, because the person is finding it difficult to adhere to the diet. I am not suggesting either is the case where your sister is concerned because I also recognize that we don’t know everything about how this diet behaves in all people. It is conceivable that there are people for whom this kind of diet will not work for reasons that we don’t necessarily understand.

    In terms of using insulin, my position is that there is some benefit in the early use of exogenous insulin in terms of preserving beta-cell function. However, in reality, the general approach to the use of insulin is so cavalier that people are actually encouraged to use it as a licence to indulge in carbs. This is crazy in my opinion. Carbs should be minimized even if you are using insulin to ensure you are taking the smallest dose possible. Dr Richard K Bernstein wrote the book on this for type 1 diabetes and I think it applies to type 2’s who need insulin, as well (as does he, of course).

    I am sorry I don’t have more to contribute in terms of resolving your sister’s dilemma. I do wish her luck in achieving the benefits of LCHF.

  9. I read with interest several questions & answers above re. salt and salts/cramping. I’m wondering about references although I suspect they would have been posted if they were known. VERY briefly: In keeping with diet reccs of his Dr. for blood pressure, my husband and hence our house eliminated excess salt in our diets. Problem: I am exercizing to lose weight and had cramps both during exercize and bad ones at night. I began to add salt back in, esp. potassium. We have now switched to a low-carb diet (we are both pre-diabetic) and have lost considerable weight. We have both recent Art & Sc. of Low-Carb books by Phinney/Volek where I found mention of higher sodium excretion on low-carb AND dizziness associated with low sodium (which was also a problem during exercize for me). I understand the need for balance between Na/K, and Ca/Mg, and Zn/Fe etc. My question: How do I figure out what that is? So far my home remedy is to make my own sports drink without the sugar and taking Ca/Mg vitamin pills. I just keep tweaking the amounts and combinations. This has drastically reduced the number/severity of cramping but has not totally eliminated it. Where can I find a good guide to calculating salt(s) requirements & balances??? Thanks for reading!

    Dr Jay’s Reply:

    I learned about the natriuretic effect of the diet and the need for Mg++ from Dr Steve Phinney. I have seen some papers on the retention of Na+ by the kidney when insulin levels and fructose intake are high. In my opinion, I don’t think you need to worry about eating a precise balance of electrolytes since your body will sort it out if everything else is working properly. The development of Na+ retention and Mg++ deficiency occur because you are eating a poor diet, high in refined carbs and when you change that your body will equilibrate as long as you are getting enough of the electrolytes in question. For example, with Na+ you don’t really need to worry about getting just the right amount as your kidney will excrete any excess. Also, the balance between K+ and Na+ will equilibrate if you are getting enough K+ in your diet. With Mg++, Dr Phinney felt is was important to take a slow release preparation as your body cannot absorb it quickly, hence my recommendation to take mag64. I take one a day plus I eat a lot of greens which tend to be high in Mg++. Nuts and seeds are also good sources although I find I have to watch it with nuts as I tend to eat too many.

  10. I can relate to the situation that you have described above. I struggled with my type II diabetes and its management for years and years. I consulted with so many people hoping that I can live a normal life but to no avail.

    About three months ago, I started on a low carb or mostly protein diet and as a result I lost some weight around 5kg in the first month of being on this diet. In relation to your struggle or that of your sister’s weight loss issue, may I suggest that you have her insulin level checked please. I suspect it is rather high hence the reason for lack of progress as regards her failed attempts to lose weight.

    I do agree with the view expressed above that she is eating carbs. (carbs and sugar is the same thing). How about avoiding processed foods altogether if she is consuming such foods? Processed foods tend to have hidden carbs.

    Anyway, the answer lies in having the insulin level around 5. If it is higher then weight loss will be a problem. How does one reduce or lower insulin? Well, the route is via a high protein diet. Certain foods namely bread, pasta, potato and rice should not be consumed at all. Only carbs in vegetables; green vegetables, should be consumed.

    Finally, this is a slightly disjointed response but the key message is clear namely that protein is the mainstay of the diet.

    Lastly, my own conclusion about the diet follows:- I feel great, my energy levels are high, concentration is increased markedly and am regaining my life back. Anyone who follows this diet can have similar results.

    Do you need experts to advise you or need to read the latest book? No. Just eat foods that require no insulin and just that.

    Dr Jay’s Reply:

    Too much protein can be a problem. When you start the diet and are burning off body fat, you can get away with eating less dietary fat and your proportion of protein will be high as a result (the absolute amount shouldn’t be too high, however). Once weight loss stops, you will need to add fat to your diet to make up for those internal fat calories you are no longer getting. It is, in the end, a high fat diet, not a high protein diet.

  11. Hello Dr Jay

    We talked last night at Dr Marks… (I mentioned I found your ‘new’ site considerably different from your old one and didn’t find the comments section — found it now )
    — first a suggestion about your web site… on your main page you should change the name of “Ground Rules” to “Comments” or “Blog Postings” ….. and once it is opened — “login or register to post comments” should be near the top between the ground rules and the comments themselves… at the moment it is only at the bottom, where it isn’t easily seen.

    Will add a few comments regarding the diet and my success on it later… but at the moment I have to get ready to head to hockey….

    again… it was a great talk you gave last night, much appreciated ,,,, and hopefully one of these days the rest of the medical world will catch up with you… 🙂

    Ron Poulter ,,,, Nanaimo BC

    Dr Jay’s Reply:

    Thanks for the suggestions. I agree, I really should do some things to improve this site. Right now, however, the main impediment is time, with a second one being lack of competence.

  12. Hello there

    I just want to thank Dr Jay for all his good work on low carb diet… I joined on in Feb of 2012 and was someone trending to Metabolic Syndrome. It is now Dec 2012 and all of my results say I’m no longer trending to anywhere except better and better health. 🙂

    The major difference for me has been weight loss…. 70 lbs from Feb to Dec. 🙂

    At 66 I still play Oldtimers Hockey and am enjoying it so much more with the weight loss… And I have no problem at all regarding energy on this diet. No carb loading, or specific carb intake prior to a game is needed — lots of get up and go….

    Still need to loose another 30 lbs (yes I was that overweight) — hopefully will have it off by early spring 2013 —- ….

    Again — many thanks Dr Jay — keep up the good work …..

    Ron —- Nanaimo BC

    Dr Jay’s Reply:

    You are to be congratulated for those excellent results. I am glad you were able to improve you health with this diet.

  13. Questio QQuestion: Has anyone looked into a low carb diet and depression? I asked this because my MD once mentioned that depression and being a carb “junkie” were quite often linked due to the short-term relaese of seratonin when carbs are consumed. Any thoughts?


    Dr Jay’s Reply:

    I believe there is a link between mood disorders and carbohydrates. Dr Roger McIntyre heads a mood disorder clinic in Toronto and has been publishing on this topic. He argues that depression should be part of metabolic syndrome. We actually had prepared a clinical trial to test a low-carb diet in his patient population but the funding got tied up in the bowels of the bureaucracy and the study was unable to proceed. I routinely see improved mood in people who start a LCHF diet. It is hard to discern what exactly causes this since there are many factors at play. I do think a well-designed clinical trial is warranted to find out whether there is a therapeutic benefit.

  14. Dr. Jay:

    Abbott and Novo now have glucose readers that will test for B-OHB by just using a different strip. B-OHB strips are about $1.80 each. My thought is that using this to determine how your CHO intake affects ketogenesis by testing your levels would be more accurate than using the scale. My reading of the literature suggests that maintaining a B-OHB level of between 1 to 3 mMol/L should suffice. Your opinion would be appreciated. thanks,

    Dr Jay’s Reply:

    This reminds me of my first endocrine lecture in med school where the professor said, “look at the whole patient, not just the lab value”. I think that there are going to be individual variations in how much ketone one produces for any given low-carb intake. Many people find ketostick urine tests useful as they provide positive feedback that the carbs are sufficiently low to induce ketosis. Having said that, what people really want to see is a reduction in fat mass and improvements in energy and well-being. People pretty much achieve those results if they get the carbs low enough. Failure usually means carbs are sneaking in somewhere or, for some, perhaps protein consumption is too high. I tend to focus on those things rather than the actual ketone values. For somebody who is struggling to get the carbs low enough, perhaps a meter would provide the feedback they need. In general, however, I don’t think it is terribly important to measure ketones to succeed with the diet. And, I do find the testing strip costs to be a bit on the expensive side.

  15. Hi Dr. Jay,

    Looking forward to your further posts. I saw this, and thought you might be interested. So far, I have read chapter one, and chapter 7 by downloading. The book emphasized how important the fat was to the hunters, and how much trouble they went to get the fat from the bone marrow, and the book mentioned the fat being healthy, and the meat without the fat being not as healthy.

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