Another Bone to Pick with Dr Fung

Another point I disagree with Dr. Fung is on the subject of Electrolytes. Dr Fung’s book, The Complete Guide to Fasting, leads many people to think that they don’t need electrolytes while doing Extended Fasting. They reach that conclusion from soundbites like the chapter heading:

Electrolytes Remain Stable (TCGtF, p 49)

And

Prolonged studies of fasting have shown no evidence of electrolyte imbalances…

This is led many to conclude that they don’t need to be concerned about electrolytes during extended fasting.

This is further exacerbated by Dr Fung being a clinician, IE, Dr Fung runs a weight loss clinic. He has thousands of patients and if he says that electrolytes are not needed then they are not needed… Or so the logic goes.

However, there are many others in the keto community who will tell you that they got into serious trouble by ignoring electrolytes. In particular, they had to end fasts due to electrolyte levels being way too low and some have ended up in the ER getting electrolytes via IV bags.

Looking at What Fung Actually Says

Fung’s book has different messages on electrolytes depending upon the fasting length.

p.48-49 During short-term fasts, salt depletion is not a concern.

p. 49 During prolonged fasting (more than a week) the kidneys are able to reabsorb and retain most of the salt needed by the body. However, some salt supplementation may be required.

People seem to miss the second part (on Extended Fasting).

There very little guidance on supplementation in the book, but several examples are found in the book (p. 240):

Dizziness
If you experience dizziness during your fast, most likely, you’re becoming dehydrated. Preventing this requires both salt [ed: Sodium and Chloride are two electrolytes] and water.

The same advice is given for headaches on the same page.

Also (p 241):

Muscle Cramps
Low magnesium, which is particularly common in diabetics, can cause muscle cramps. You may take over-the-counter magnesium supplement.

Facts Keep Getting in the Way

I have a serious concern with Dr. Fung’s method when it comes to Extended Fasts and the evidence against needing electrolytes. On p 50, Dr. Fung has Figure 1.4 which states in the legend:

Figure 1.4 Electrolytes remain stable during extended fasting

The book shows charts for Chloride, Potassium and Sodium.

But what is missing from these charts? What is in the charts themselves? And, who is the subject of the charts?

The charts are from the Guiness Book record holder for longest extended fast, Angus Barbieri. I have written about Angus’ fast. His fast was medically covered in this study (Stewart, Features of a successful therapeutic fast of 382 days’ duration).

Angus was a big man

There are some significant things of note. Angus was 456 lbs at the start of his fast. To use his extreme situation as evidence that electrolyte supplements are not needed during an extended fast is sketchy at best since he had so much available substrate to draw from during his fast.

Missing Data?

Further, Dr Fung omits in his book Angus’ Magnesium (Mg) levels which were published in the study and did show him with low Mg levels for much of the fast. The Normal range is clearly marked and the points are below that line. This is the figure from the study itself.

As you can see Angus’ Magnesium levels did drop during his fast very quickly and were on the low range of normal for almost the entire fast.

Fung doubles down with the statement (p 228):

While monitoring the world-record-breaking 382 day fast, researchers measured the magnesium content within the cells, which remained firmly in the normal range.

Dr Fung does go on to note (p 229) something ignored by many:

Nevertheless, we often supplement patients with magnesium to be on the safe side.

Did Angus Get Supplements?

The study also clearly notes that Angus was given supplements for the entire duration of his fast:

During the 382 days of his fast, vitamin supplements were given daily as ‘Multivite’ (BDH), vitamin C and yeast for the first 10 months and as ‘Paladac’ (Parke Davis), for the last 3 months.

I am not sure if the formula for Multivite has changed between the mid 1960’s and today, but the current formula is:

As you can see, Angus was actually given Magnesium, Potassium, Calcium and Phosphorus during his fast in the form of a supplement. Not in high dosage but not ZERO either.

Did Angus Receive Other Electrolytes?

The most serious issue with respect to Dr Fung’s claims about Angus’ fast however, is the study indicates that Angus actually did receive additional electrolytes during the fast.

From Day 93 to Day 162 only, he [sic: Angus] was given potassium supplements (two effervescent potassium tablets BPC supplying 13 mEq daily) and from Day 345 to Day 355 only he was given sodium supplements (2.5 g sodium chloride daily).

Here’s the chart from Dr Fung’s book which clearly shows Angus’ Potassium levels dropping below normal to the point where he was given potassium supplements (day 93 in the study). They went up to normal after Angus was given the Mg supplements and even after he discontinued the supplements.

Conclusions

Angus Barbieri is an example where electrolyte supplementation was required which is the exact opposite of what Dr Fung says in his book. Angus Barbieri was not only given Potassium when his levels fell, he was also given Sodium Chloride for another portion of his fast. He also had a daily vitamin which contained these elements.

Angus Barbieri was medically monitored and tested during his extended fasts. The doctors could tell when to supplement and when it was unnecessary.

It is a serious mistake to use Angus Barbieri as evidence that electrolyte supplementation doesn’t need to be done in Extended Fasting. Fung’s book on this subject is sloppy and ignores the evidence in the study. It sends a mixed message in the practical advice section later in the book from what it sent in the earlier part of the book.

 

Protein Sparing Modified Fast Calculator

I put together the previous formulas into one single webpage, the Protein Sparing Modified Fast Calculator. I’ve put my own current numbers into the calculator. Just hit the “Calculate” button to see my numbers. Feel free to try it out with your own numbers and see if it helps you figure out any of this. I don’t see the numbers you enter nor are they stored in any database. All of the calculations are done on your phone web browser or Internet browser (Firefox and Chrome works but Internet Explorer doesn’t).

If you find any errors, please let me know. I tried it with my own numbers and they make sense but I didn’t have a woman’s secret numbers to check.

Here’s a decent introduction to the Protein Sparing Modified Fast (PSMF). I only take exception to one point which is the question of how long you can do a PSMF. They say you can’t do it for an extended period of time. If you continually re-calculate your numbers you should be able to fine tune for maintenance levels. This calculator makes that re-calculation relatively easy. Here’s the results I got for my numbers.

Your Scale and Metabolism Numbers

Current Weight: 199.8 lbs
Goal Weight: 171.3 lbs
Lbs from Goal Weight at start: 28.5 lbs
Body Fat at start: 25.4%, 50.8 lbs
Lean Body Mass (LBM): 149.0 lbs
Basal Metabolic Rate (BMR): 1818.0 cal/day
Initial Total Daily Energy Expenditure (TDEE): 2500 cal/day
Initial Maximum Fat Loss on Protein Sparing Modified Fast: 0.45 lbs of body fat per day

Notes

Protein Sparing Modified Fast (PSMF) Dietary Macros (per day)

It is very important on the PSMF that you eat at least the macros listed here. If you go below these numbers you risk lowering your metabolism and you actually can’t lose body fat any faster. Attempting to be just above the numbers is OK.

Protein: 119.2 g (476.8 cals)
Carbs: 20 g (80 cals)
Fat: 40.9 g (367.7 cals)
Your total Dietary Calories are 924.4 cals for maximum fat loss.

If you consume 216 g (1943 calories) of fat you will stay at your current weight.At your goal weight you will be able to consume 119.2 grams of Protein, 20 grams of Carbs, and 176.3 grams of Fat.

Notes

Can You Fast?

One important question to ask when considering extended fasting is whether or not you have sufficient body fat to fast.

You currently use 2500 cal/day. You have 1575 calories per day available from your body fat for maintenance. You have less calories available from body fat than your daily requirements and may not be able to fast. If you fast, your body may drop your base metabolism, energy expenditures or may consume protein stores. You will be -924 calories short per day

The thermic effect of food contributes somewhere from 5-20% of your current TDEE number so if you are fasting that can reduce your TDEE. Reducing your TDEE by 10% would result in you using 2250 calories per day. Calculating in a 10% Thermic Effect of food still leaves you in a caloric deficit during fasting. The Protein Sparing Modified fast solves this issue by providing the calories needed for the deficit.

How Much Muscle Can You Gain?

The Maximum Lean Body Mass that you can carry on your frame is 186.5 lbs at your goal of: 15.0% Body Fat. That would be a weight of 214.5 lbs.

Disclaimer

Use this information at your own risk and with the advice of your medical professional. We are not doctors nor do we pretend to be one on the Internet. We do not take responsibility for errors in these calculations. We do not guarantee that these numbers will work for people at the extremes of the ranges. If you discover an error in calculation, please let us know through email: keto at land-boards dot com.

Do Calories Matter?

The first question is “Do Calories matter in what?”. If the “what” is weight-loss then the question is, “Do Calories matter in Weight-loss?”.

The answer is both yes and no. The standard formula Calories In minus Calories Out has many problems including:

  • Doesn’t differentiate between the sources of calories. In this formula 1000 calories of seven layer chocolate cake is the same as 1000 calories of broccoli (although try to eat 1000 calories of broccoli sometime).
  • At a finer level, doesn’t differentiate between the macro-nutrient mix of two things. Is a 200 calorie bag of chips really the same as a 200 calorie bag of macadamia nuts? The chips are carbs and fat as are the nuts but the proportions of fats and carbs are completely different between the two.
  • Within a particular macro-nutrient it also doesn’t differentiate between types of macro-nutrients or how the body processes them.

So where/how do calories matter?

Since the subject of this BLOG is largely Ketogenic diets it is a given that the Low Carb (less than 20 grams of net carbs a day) is the baseline. There’s plenty of science that shows this is an effective and safe diet. But what does that leave? There are only three macro-nutrients (and we aren’t counting the fourth which is alcohol) so that only leaves fat and protein.

Let’s Look at Protein First

Here’s where it gets controversial or fun, depending on your own tolerance for different opinions. You need some amount of protein to maintain your Lean Body Mass. Fasting has been shown to be sparing of lean body mass, but there’s some minimal loss on longer fasts. At one end of the spectrum is Dr Jason Fung who’s patients are often older and present to him with diabetes and other metabolic disorders. He prescribes a limit on protein (How much protein is excessive?):

The average necessary would be 0.6 g/kg/day (around 50 g/day) and LESS if you are trying to lose weight.

The value of 0.6g/kg of body mass translates to 0.27g/lb of body mass. Note Fung’s number is not for Lean Body Mass, but current weight. Let’s round to 0.3 to make the math easier here.

At the far other end are bodybuilders who have much higher macros. But the focus here is ketogenic eating, Here is the KetoGains suggested intake of protein (KetoGain FAQ):

*Sedentary people: 0.69 to 0.8g per lean pound
*Mildly active or doing endurance / strength training: 0.8 to 1.0g per lean pound
* Heavy strength training / bodybuilders / PSMF: 1.0 up to 1.2g per lean pound

So picking the middle number would be 0.9g/lb of LBM. There’s no easy translation between LBM and body weight since it varies greatly person to person. The formula is:

Body weight times (1-fat percentage) = Lean Body Mass (LBM)

For the sake of simplification, let’s assume that the person has 25% fat. Their LBM is 0.75 times their body weight. For a 200 lb person that would be an LBM of 150 lb.

The protein recommendation of Dr. Fung for maintenance is then 200 x 0.3g/lb or 60 grams. The protein recommendation of KetoGains would be 150 x 0.9 = 135 or a bit more than twice that of Dr Fung.

Note the different goals. Dr. Fung’s number is based on the goal of maintenance of LBM and the KetoGains number is based on body recomposition or growth in muscles.

In the end this is a fixed value which should be adhered to – if possible on a daily basis.  And what this means is that the number of calories (4 times the number of grams of protein) is also a fixed number and is specific to your current body weight, etc. If you are a 200 lb male with 30% body fat that translates to 135 grams a day (KetoGains model).

The Only Thing Left is Fat

And surprisingly, fat is also controversial. But it really shouldn’t be. The standard keto advice is eat until satiety. But for many of us that’s a hard point to discover. We’ve eaten until we are stuffed for so long that we are barely able to do otherwise. And fat becomes what we use to feel really full. And fat is very dense.

The Problem with eating too much fat is that we don’t pull fat stores from our bodies when we overdo fat. That is why most of us stall in our losses. We don’t gain weight if we keep low carb because it’s really the carbs which make us fat not the dietary fat. But we are not losing weight either.

How Much Fat Should We Eat?

If you are asking this question it’s because the standard “Eat till satiety” isn’t working for you any longer. In the beginning it worked well but the real reason is that your body had a lot of fat stores to pull from. As we go on in this Way of Eating our bodies have less and less reserves of fat to eat.

There’s a constant called the fat oxidation rate which limits our ability to pull fat from our bodies (A limit on the energy transfer rate from the human fat store in hypophagia). That number is 31 calories per lb of fat mass per day. If you have 50 lbs of fat mass you can only pull around 1500 calories a day from that fat mass. On a long fast, if you pull more calories that comes either out of dropping your metabolism or your body’s protein stores. There are no other sources. And usually it is your metabolism which drops. Some of this is made up by the thermogenic effect of food (you are not burning energy to eat food).

So some of us have tried doing reduced calorie diets without concern for our macro-nutrients. We don’t need carbs (we are keto, right) so there’s only two choices when reducing calories. Either we reduce protein or we reduce fat. If we spare the protein by eating enough (see above) then we have to strike the balance at the cost of lowering our fat consumption.

And lowering fat consumption makes a lot of sense. It’s often easy to not put a stick of butter on a pile of broccoli. It tastes just as good if you have been doing keto for a long time and in essence, the fats are just wasted calories. They won’t make you fat (it takes carbs plus fat to make you fat) but they won’t make you thinner either.

The amount of fat we should eat should be set by the maximum rate of loss that we can do through fat oxidation. You can always choose to go slower, but how many people want to do that? A cheat day would consist of over consuming fat which would be a stall and not a weight gain. But you don’t need to cheat.

The Maths

The Math is described here. In outline it works like this:

  • Get some measurements (Weight, simple body tape measurements)
  • Determine your assumptions (Base Metabolic Rate, Protein needs)
  • Set your goal (Body fat percentage is the sole goal)
  • Run the numbers to determine the results (end weight, weight loss time, macros for each day)
  • Pick your foods to reach your goals depending on each day’s needs
  • Chart your progress as you do it

The Don’ts

  1. Don’t use this information to help your anorexia or some other eating disorder. There’s some ways to help with that like not looking in a mirror but look at a picture of yourself to see what you really look like to others. I did that and I looked fat in the viewfinder but not fat in the picture itself. Same with mirrors.
  2. Don’t set unreasonable goals. Don’t go for 5% body fat. There are safe numbers out there for body fat percentages. You are may not be the best judge of what is good for you (particularly if you have a food disorder). Trust those numbers out there and not your own perceptions of whether or not you are fat.
  3. Don’t try to cook the numbers. By that I mean don’t try to run at a calorie deficit to get it done sooner.
  4. Don’t just run the numbers once and stick to the same pattern for the next three months. At least recalculate the numbers and readjust weekly. The numbers shift quickly on this method. You may be eating almost no fat one day and need to supplement more as you go on.
  5. Don’t forget to track all of your macros. It’s not all that hard. You already know how to keep your carbs below 20 but track them anyway. Tracking the macros lets you check against the model.
  6. Don’t cut protein to accelerate weight loss. Eat protein in a consistent way. I am choosing to use Protein Powder. May not be the right choice for others. Let’s me isolate protein from the other macros.
  7. Don’t cut fat to accelerate weight loss. You will sabotage yourself by lowering your metabolic rate too far.
  8. Don’t overdo but if you overdo then make it fat that you overdo not protein or definitely not carbs. Know that too much fat slows weight loss.

Final Thoughts

The math here can be daunting. But there are calculators for every part of it on the Internet. If you don’t like the calculators you can get measured with BodPod or DEXA to get more precise body fat numbers. More precision probably doesn’t matter in most cases but if you get close to your goals it may matter.

Bottom line is:

  • Keep keto for carbs (less than 20 grams a day)
  • Eat the proper protein amount
  • Eat the amount of fat calories you need to reach your Total Energy Expenditure (minus the calories of fat your body can oxidize)

You can break your stall.

Chia Seeds

I referred to Chia Seeds in another BLOG post as part of my refeeding strategy for ending extended fasts.

Chia Seeds are one of those SuperFoods which should be a part of our diet. They provide a lot of fiber and very few calories. One ounce (about 2 tablespoons) contains 139 calories, 4 grams of protein, 9 grams fat, 12 grams carbohydrates and 11 grams of fiber, plus vitamins and minerals.

For Low Carb folks the 12 grams of carbohydrates are before subtracting fiber so the net carbs are 1-2.

To use them I soak the seeds in water (1/4 cup seeds to 1 cup liquid) until they take on a chewy texture reminiscent of tapioca pudding, about 20 minutes. Soaked chia seeds can be refrigerated for up to 5 days, so you can make a big batch at the start of the week.

I eat them one day before ending a longer (more than 7 day) fast. I also eat them three hours before refeeding. I usually eat them with a dill pickle which acts as a Sodium bomb.

 

Tapped Out at 25 Days

I made it 25 days on my Water Only Fast. Ended yesterday. I miss fasting already. Felt better while fasting than I do on food. Ended with Chia Seeds and a pickle. The Chia Seeds act like a slowly moving cork through the system which is good after a long fast.

Thinking about doing Chia Seeds once a day on my next fast. Won’t technically be a water fast, but I like the idea of keeping some fiber moving through my system. I am just a few lbs over my goal weight so I am not in all that much of a hurry.

Weight loss was 24 lbs. Should hang onto a lot of it since I really kept up on salt.

Can’t wait to do my next Extended Fast. Maybe after the Keto meetup this weekend.

Tomorrow is my third intro class to CrossFit then I can join the regular people in torturing myself. I know that this will be much harder than Keto and Intermittent Fasting. And I will definitely keep up the Intermittent Fasting and Keto. Never going to give up the gains I have made with Keto + IF.

Preliminary Thoughts on Exercise

My Original Goal

At the start of this experience my goal was to Hack My Type Two Diabetes. Per my MD, I am no longer a diabetic and am just at the bottom end of the Pre-Diabetes range. So mission accomplished???

Are We There Yet?

My initial observation was that Diabetes is just a symptom of the underlying condition which is Insulin Resistance. Eating Low Carb. Moderate Protein and High Healthy Fats reduces the need for the body to produce Insulin but does it cure Insulin Resistance itself?

What is Insulin Resistance?

Insulin Resistance is the inability of the body’s cells to take in glucose in the presence of Insulin. From Skeletal Muscle Insulin Resistance Is the Primary Defect in Type 2 Diabetes.

Under euglycemic hyperinsulinemic conditions, ∼80% of glucose uptake occurs in skeletal muscle

If your muscles are not able to efficiently take up glucose then you have Insulin Resistance. It may be that exercise is the only way to improve glucose uptake in the muscles.

Types of Exercise

When it comes to improving Insulin Resistance, I think there may be a difference between the sorts of exercise, ie, aerobic and anaerobic exercise. Repeatedly dumping all of the glucose out of the cells is part of what is needed to increase insulin sensitivity. That seems like where High Intensity exercise comes into play. Things like rapid reps of high weights vs walking on a treadmill.

My Experience with Exercise

This would bear out with my own experience of the quick dump of glucose that I experienced in the high intensity workout. My glucose went up at least 80 points which I now think is due to Insulin Resistance. Not only is the liver dumping in that case but the muscles are dumping too. And that’s a good thing.

So perhaps if I got this right it’s more about the type of exercise when attempting to improve the underlying Insulin Resistance than it is about the exercise itself. Is it true to say the reason my blood sugar rises so high with high intensity exercise is that my muscle cells are still Insulin Resistant and that with more exercise they will get better at responding to the Insulin they are given and then I will not see high blood sugar spikes during and immediately after exercise?

If I have this right I should easy be able to measure and observe progress by checking my blood sugars after exercise to exhaustion and the levels should drop.

Here’s a pretty good article on the subject.

So why LCHF and Fasting?

Using LCHF + Fasting has helped me get to a weight where my pulse rate is lower, the stress on my joints is lower, my BP is lower and I am now at the point where I can safely exercise. Surely my Insulin Resistance is somewhat better but the only real way to attack it that is left is with high intensity exercise.

Navigating the Maze of Facebook Keto Groups

I really want to make some sort of map or list of questions that shows the groups and their “pet peeves”. The sorts of things include:

  1. Is taking Insulin good? Bernstein people say yes because their goal is lowest blood sugars. Keto people say no because they believe that more Insulin is more Insulin Resistance which is the root cause.
  2. Protein macros. Ketogains folks believe in 2-3 times the protein of most other keto groups. Other keto groups focus on the Insulin response of the body to protein. Too much protein although it doesn’t immediately raise the blood sugar does have a significant Insulin response so they keep it low. (Fung vs Finney/Volek).
  3. Exercise or not? Many keto groups say don’t exercise and point to the studies which show that diet plus exercise doesn’t lose any more weight than diet alone. Other groups are all about exercise and point to their physiques as evidence (and some are spectacular). They argue it is more about fitness than weight.
  4. Fasting. Most keto groups are starting to catch onto fasting. Some are not.
  5. What constitutes fasting? One group has a very, very specific list of things that you can consume while fasting and specifically excludes things like dry fasting.
  6. I think for the most part that the keto community agrees with the 20 grams or less of carbs a day but there may be differences with subtracting fiber when calculating. Certainly some have flexibility when it comes to additional vegetables.
  7. Artificial sweetners. Again various opinions on their positive and negative values.
    There are probably a lot more dimensions to this but those are the ones that come to mind.The best piece of advise I can give anyone is to read the pinned post when you join a Keto Facebook group. Most groups will ask you to do that and if you don’t agree with the pinned post don’t make it your personal mission to convert the group to your point of view. Just leave the group.

What my Doctor Said

I got off Insulin a year ago so I haven’t needed to go to my MD in two years. I decided for the one year anniversary of starting ketogenic eating to go to my doctor and get my blood tests. So I anxiously checked my email for the results of my blood tests.

The number I was most interested in was the HbA1C number. That’s the measurement of the average blood sugar level of the past three months. The test showed my HbA1C to be 5.8. That is at the bottom of the Pre-Diabetic range. 5.6 or less is considered to be non-diabetic. The value of 5.8 is an average Blood Glucose value of 120. That matches pretty well what my meter shows.

The doctor told me he has never seen this before or heard of this happening to anyone. I told him how I did it (documented in this BLOG). How I took off a week from work and decided I was going to figure out how to Hack my Type 2 Diabetes.

I recommended that the doctor look up Jason Fung and find some of his videos on Diabetes. Here’s one that YouTube has:

Blood Glucose Levels Over the last Three Months

Here are my blood glucose numbers over the past three months. I have been fasting the last week so the number are lower during the fast. This is an average of 113, and a HbA1c of 5.7. The normal range for level for hemoglobin A1c is less than 6%. Note that I am still taking Metformin. I am also doing High Carb, Healthy Fats plus Intermittent Fasting.