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The Ketogenic Diet PDF

323 Pages·2001·0.68 MB·English
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The Ketogenic Diet: A complete guide for the Dieter and Practitioner Lyle McDonald This page intentionally left blank. Page down to view The Ketogenic Diet This book is not intended for the treatment or prevention of disease, nor as a substitute for medical treatment, nor as an alternative to medical advice. It is a review of scientific evidence presented for information purposes, to increase public knowledge of the ketogenic diet. Recommendations outlined herein should not be adopted without a full review of the scientific references given and consultation with a health care professional. Use of the guidelines herein is at the sole choice and risk of the reader. Copyright: © 1998 by Lyle McDonald. All rights reserved. This book or any part thereof, may not be reproduced or recorded in any form without permission in writing from the publisher, except for brief quotations embodied in critical articles or reviews. For information contact: Lyle McDonald, 500 E. Anderson Ln. #121-A, Austin, Tx 78752 ISBN: 0-9671456-0-0 FIRST EDITION SIXTH PRINTING 3 Acknowledgements Thanks to Dan Duchaine and Dr. Mauro DiPasquale, and before them Michael Zumpano, who did the initial work on the ketogenic diet for athletes and got me interested in researching them. Without their initial work, this book would never have been written. Special thanks to the numerous individuals on the internet (especially the lowcarb-l list), who asked me the hard questions and forced me to go look for answers. To those same individuals, thank you for your patience as I have finished this book. Extra special thanks go out to my editors, Elzi Volk and Clair Melton. Your input has been invaluable, and prevented me from being redundant. Thanks also goes out to everybody who has sent me corrections through the various printings. Even more thanks to Lisa Sporleder, who provided me valuable input on page layout, and without whom this book would have looked far worse. Finally, a special acknowledgement goes to Robert Langford, who developed the 10 day ketogenic diet cycle which appears on pages 150-151. 4 Introduction I became interested in the ketogenic diet two and one-half years ago when I used a modified form (called a cyclical ketogenic diet) to reach a level of leanness that was previously impossible using other diets. Since that time, I have spent innumerable hours researching the details of the diet, attempting to answer the many questions which surround it. This book represents the results of that quest. The ketogenic diet is surrounded by controversy. Proponents of the ketogenic diet proclaim it as a magical diet while opponents denounce the diet because of misconceptions about the physiology involved. As with so many issues of controversy, the reality is somewhere in the middle. Like most dietary approaches, the ketogenic diet has benefits and drawbacks, all of which are discussed in this book. The goal of this book is not to convince nor dissuade individuals to use a ketogenic diet. Rather, the goal of this book is to present the facts behind the ketogenic diet based on the available scientific research. While the use of anecdotal evidence is minimized, it is included where it adds to the information presented. Guidelines for implementing the ketogenic diet are presented for those individuals who decide to use it. Although a diet free of carbohydrates is appropriate for individuals who are not exercising or only performing low-intensity aerobic exercise, it is not appropriate for those individuals involved in high-intensity exercise. In addition to the standard ketogenic diet, two modified ketogenic diets are discussed which integrate carbohydrates while maintaining ketosis. The first of these is the targeted ketogenic diet, which includes the consumption of carbohydrates around exercise. The second, the cyclical ketogenic diet, alternates a span of ketogenic dieting with periods of high-carbohydrate consumption. In addition to an examination of the ketogenic diet, exercise is addressed, especially as it pertains to ketogenic diets and fat loss. This book is divided into seven parts. Part I includes an introduction to the ketogenic diet and a history of its development. Part II presents the physiology of fuel utilization in the body, ketone bodies, the adaptations to ketosis, changes in body composition, and other metabolic effects which occur as a result of ketosis. Part III discusses the specific diets presented in this book. This includes a general discussion of dieting principles, including body composition and metabolic rate, as well as details of how to develop a standard, targeted, and cyclical ketogenic diet. Part IV completes discussion of the ketogenic diet with chapters on breaking fat loss plateaus, ending the diet, tools used to enhance the diet, and concerns for individuals considering using ketogenic diet. Part V discusses exercise physiology, including aerobic exercise, interval training, and weight training. Additionally, the effects of exercise on ketosis and fat loss are discussed. Part VI develops general exercise guidelines based on the information presented in the preceding chapters. Part VII presents sample exercise programs, as well as guidelines for pre-contest bodybuilders. Finally, Part VIII discusses the use of supplements on the ketogenic diet, both for general health as well as specific goals. This book is meant as a technical reference manual for the ketogenic diet. It includes 5 information that should be useful to the general dieting public, as well as to athletes and bodybuilders. Hopefully, the attention to technical accuracy will make it useful to researchers and medical professionals. As such, technical information is necessarily presented although attempts have been made to minimize highly technical details. Over 600 scientific references were examined in the writing of this book, and each chapter includes a full bibliography so that interested readers may obtain more detail when desired. Readers who desire further in-depth information are encouraged to examine the cited references to educate themselves. Lyle McDonald Bio: Lyle McDonald received his B.S. from the University of California at Los Angeles in physiological sciences. He has written for several publications, including two web magazines (Cyberpump and Mesomorphosis), two print magazines (Hardgainer and Peak Training Journal), and two newsletters (Dave’s PowerStore Newsletter and Dirty Dieting). 6 Foreword REGULATION OF KETOGENESIS (Sung to the tune of “Clementine”) In starvation, diabetes, sugar levels under strain You need fuel to keep going saving glucose for your brain Ketone bodies, Ketone bodies, both acetoacetate And its partner on reduction, 3-hydroxybutyrate. Glucagon’s up, with low glucose, insulin is down in phase Fatty acids mobilised by hormone-sensitive lipase Ketone bodies, Ketone bodies, all start thus from white fat cell Where through lack of glycerol-P, TG making’s down as well. Fatty acyl, CoA level, makes kinase phosphorylate Acetyl-CoA carboxy-lase to its inactive state Ketone bodies, Ketone bodies, because glucagon they say Also blocks carboxylation, lowers Malonyl-CoA. Malonyl-CoAs a blocker of the key CPT-1 Blocking’s off so now the shuttle into mito’s is begun Now we’ve ß oxidation, now we’ve acetyl-CoA But what’s to stop it’s oxidation via good old TCA? In starvation, glucose making, stimulating PEP CK Uses oxaloacetic, also lost another way Ketone bodies, what is odd is that the oxidation state Also favours the reduction of OA to make malate. OA’s low now, citrate synthase, thus loses activity So the flux into the cycle cuts off (temporarily) Ketone bodies, Ketone bodies situation thus is this Acetyl-CoA’s now pouring into Ketogenesis. It’s a tricky little pathway, it’s got HMG-CoA In effect it’s condensation in a head-to-tailish way Ketone bodies, Ketone bodies, note the ratio of the pair Is controlled by NAD to NADH everywhere. Don’t despise them, they’re good fuels for your muscles, brain and heart When you’re bodies overloaded though, that’s when your troubles start Ketone bodies, ketone bodies, make acetone, lose CO2 You can breath those out, but watch out - acidosis does for you! © “The Biochemists’ Songbook, 2nd ed.” Harold Baum. London: Taylor and Francis Publishers, 1995. Used with permission. 7 8 Table of contents Part I: Introduction 19. Interval training 200 1. Introduction to the ketogenic diet 11 20. Weight training 206 2. History of the ketogenic diet 13 21. The effect of exercise Part II: The physiology of ketosis on ketosis 225 3. Fuel utilization 18 22. Exercise and fat loss 229 4. Basic ketone body physiology 28 Part VI: Exercise guidelines 5. Adaptations to ketosis 38 23. General exercise guidelines 239 6. Changes in body composition 52 24. Aerobic exercise 241 7. Other effects of the ketogenic diet 71 25. Interval training 245 Part III: The diets 26. Weight training 248 8. General dieting principles 86 Part VII: Exercise programs 9. The standard ketogenic diet (SKD) 101 27. Beginner/intermediate 260 10. Carbs and the ketogenic diet 120 28. The advanced CKD workout 266 11. The targeted ketogenic diet (TKD) 124 29. Other applications 270 12. The cyclical ketogenic diet (CKD) 128 30. Fat loss for pre-competition Part IV: Other topics bodybuilders 278 13. Breaking fat loss plateaus 148 Part VIII: Supplements 14. Ending a ketogenic diet 152 31. General supplements 289 15. Tools for the ketogenic diet 158 32. Fat loss 292 16. Final considerations 166 33. The carb-load 302 Part V: Exercise physiology 34. Strength/mass gains 307 17. Muscular physiology and Appendices 309 energy production 174 Glossary 312 18. Aerobic exercise 180 Index 314 9 Part I Introduction Chapter 1: Introduction to the ketogenic diet Chapter 2: The history of the ketogenic diet Prior to discussing the details of the ketogenic diet, it is helpful to discuss some introductory information. This includes a general overview of the ketogenic diet as well as the history of its development, both for medical conditions as well as for fat loss. 10 Chapter 1: 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 Under ‘normal’ dietary conditions, the body runs on a mix of carbohydrates, protein and fat. When carbohydrates are removed from the diet, the body’s small stores are quickly depleted. Consequently, the body is forced to find an alternative fuel to provide energy. One of these fuels is free fatty acids (FFA), which can be used by most tissues in the body. However, not all organs can use FFA. For example, the brain and nervous system are unable to use FFA for fuel ; however, they can use ketone bodies. 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. When carbohydrates are removed from the diet, insulin levels decrease and glucagon levels increase. This causes an increase in FFA release from fat cells, and increased FFA burning in the liver. The accelerated FFA burning in the liver is what ultimately leads to the production of ketone bodies and the metabolic state of ketosis. In addition to insulin and glucagon, a number of 11 other hormones are also affected, all of which help to shift fuel use away from carbohydrates and towards fat. 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. 12 Chapter 2: History of the Ketogenic Diet Before discussing the theory and metabolic effects of the ketogenic diet, it is useful to briefly review the history of the ketogenic diet and how it has evolved. There are two primary paths (and numerous sub-paths) that the ketogenic diet has followed since its inception: treatment of epilepsy and the treatment of obesity. Fasting Without discussing the technical details here, it should be understood that fasting (the complete abstinence of food) and ketogenic diets are metabolically very similar. The similarities between the two metabolic states (sometimes referred to as ‘starvation ketosis’ and ‘dietary ketosis’ respectively) have in part led to the development of the ketogenic diet over the years. The ketogenic diet attempts to mimic the metabolic effects of fasting while food is being consumed. Epilepsy (compiled from references 1-5) 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. Wilder is essentially identical to the diet being used in 1998 to treat childhood epilepsy. The ketogenic diet fell into obscurity during the 30’s, 40’s and 50’s as new epilepsy drugs were discovered. The difficulty in administering the diet, especially in the face of easily prescribed drugs, caused it to all but disappear during this time. A few modified ketogenic diets, such as the Medium Chain Triglyceride (MCT) diet, which provided greater food variability were tried but they too fell into obscurity. In 1994, the ketogenic diet as a treatment for epilepsy was essentially ‘rediscovered’ in the story of Charlie, a 2-year-old with seizures that could not be controlled with medications or other treatment, including brain surgery. Charlie’s father found reference to the ketogenic diet in the literature and decided to seek more information, ending up at Johns Hopkins medical center. 13 Charlie’s seizures were completely controlled as long as he was on the diet. The amazing success of the ketogenic diet where other treatments had failed led Charlie’s father to create the Charlie Foundation, which has produced several videos, published the book “The Epilepsy Diet Treatment: An introduction to the ketogenic diet”, and has sponsored conferences to train physicians and dietitians to implement the diet. Although the exact mechanisms of how the ketogenic diet works to control epilepsy are still unknown , the diet continues to gain acceptance as an alternative to drug therapy. Other clinical conditions Epilepsy is arguably the medical condition that has been treated the most with ketogenic diets (1-3). However, preliminary evidence suggests that the ketogenic diet may have other clinical uses including respiratory failure (6), certain types of pediatric cancer (7-10), and possibly head trauma (11) . Interested readers can examine the studies cited, as this book focuses primarily on the use of the ketogenic diet for fat loss. Obesity Ketogenic diets have been used for weight loss for at least a century, making occasional appearances into the dieting mainstream. Complete starvation was studied frequently including the seminal research of Hill, who fasted a subject for 60 days to examine the effects, which was summarized by Cahill (12). The effects of starvation made it initially attractive to treat morbid obesity as rapid weight/fat loss would occur. Other characteristics attributed to ketosis, such as appetite suppression and a sense of well being, made fasting even more attractive for weight loss. Extremely obese subjects have been fasted for periods up to one year given nothing more than water, vitamins and minerals. The major problem with complete starvation is a large loss of body protein, primarily from muscle tissue. Although protein losses decrease rapidly as starvation continues, up to one half of the total weight lost during a complete fast is muscle and water, a ratio which is unacceptable. In the early 70’s, an alternative approach to starvation was developed, termed the Protein Sparing Modified Fast (PSMF). The PSMF provided high quality protein at levels that would prevent most of the muscle loss without disrupting the purported ‘beneficial’ effects of starvation ketosis which included appetite suppression and an almost total reliance on bodyfat and ketones to fuel the body. It is still used to treat severe obesity but must be medically supervised (13). At this time, other researchers were suggesting ‘low-carbohydrate’ diets as a treatment for obesity based on the simple fact that individuals tended to eat less calories (and hence lose weight/fat) when carbohydrates were restricted to 50 grams per day or less (14,15). There was much debate as to whether ketogenic diets caused weight loss through some peculiarity of metabolism, as suggested by early studies, or simply because people ate less. The largest increase in public awareness of the ketogenic diet as a fat loss diet was due to “Dr. Atkins Diet Revolution” in the early 1970’s (16). With millions of copies sold, it generated 14 extreme interest, both good and bad, in the ketogenic diet. Contrary to the semi-starvation and very low calorie ketogenic diets which had come before it, Dr. Atkins suggested a diet limited only in carbohydrates but with unlimited protein and fat. He promoted it as a lifetime diet which would provide weight loss quickly, easily and without hunger, all while allowing dieters to eat as much as they liked of protein and fat. He offered just enough research to make a convincing argument, but much of the research he cited suffered from methodological flaws. For a variety of reasons, most likely related to the unsupported (and unsupportable) claims Atkins made, his diet was openly criticized by the American Medical Association and the ketogenic diet fell back into obscurity (17). Additionally, several deaths occurring in dieters following “The Last Chance Diet” - a 300 calorie-per-day liquid protein diet, which bears a superficial resemblance to the PSMF - caused more outcry against ketogenic diets. From that time, the ketogenic diet (known by this time as the Atkins diet) all but disappeared from the mainstream of American dieting consciousness as a high carbohydrate, lowfat diet became the norm for health, exercise performance and fat loss. Recently there has been a resurgence in low carbohydrate diets including “Dr. Atkins New Diet Revolution” (18) and “Protein Power” by the Eades (19) but these diets are aimed primarily at the typical American dieter, not athletes. Ketogenic diets and bodybuilders/athletes 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). During the 1980’s, Michael Zumpano and Daniel Duchaine introduced two of the earliest CKD’s: ‘The Rebound Diet’ for muscle gain, and then a modified version called ‘The Ultimate Diet’ for fat loss. Neither gained much acceptance in the bodybuilding subculture. This was most likely due to difficulty in implementing the diets and the fact that a diet high in fat went against everything nutritionists advocated. 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 would refill muscle carbohydrate stores and cause growth. The carb-loading phase was necessary as ketogenic diets can not sustain high intensity exercise such as weight training. DiPasquale argued that his diet was both anti-catabolic (preventing muscle breakdown) as well as overtly anabolic (muscle building). His book suffered from a lack of appropriate references (using animal studies when human studies were available) and drawing incorrect 15

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