An M.D. On The Plant-Based Ketogenic Fasting Plan She Follows For Health

One of the most interesting panels at 2017's revitalize was a discussion on intermittent fasting and ketosis, two buzzwords of the health world. Mention a ketogenic diet, and those who are familiar typically picture something similar to a high-fat paleo diet, heavy in animal protein and plant and animal fat.

CD: I stopped eating meat because I thought it was healthier when I was 12, and I was vegan/vegetarian for about two decades. During my 20s, this resulted in me eating mostly processed junk, which resulted in me weighing 100 pounds more than I do now. I started medical school and lost the weight eating a calorie-restricted, low-fat, mostly vegan diet. During my orthopedic residency, I started eating meat again. I gained 60 pounds with each of my pregnancies and lost the weight (again!) eating low-fat vegan and exercising. My diet at the time wasn't healthy for me; it was super carb-heavy even though I wasn't eating many processed foods. My health declined and I was gaining substantial weight. Eventually, I was diagnosed with type 1 diabetes and started eating a low-carb diet with meat to keep my insulin steady and blood sugar balanced.

CD: I have black coffee for breakfast, and then I have this smoothie starting around 1 or 2 in the afternoon. If I'm not fasting I add sacha inchi or hemp powder to it for protein. At dinner, I will have tempeh, hemp, or hempfu (hemp tofu) as a protein source. I often have natto for vitamin K2. I usually have a bunch of veggies with healthy fats like this cauliflower rice recipe, and I almost always have a salad with olive oil.

CD: I use ketosis in almost all of the patients that I do surgery on, but it is really more of a low-carbohydrate diet than true ketosis. It helps them lose weight, and since a large percentage of my patients have pre-diabetes or diabetes [editor's note: Diulus is a spine surgeon], it helps them to keep their blood sugars managed for surgery, which decreases the risk of surgical complications, like infection or wound-healing problems.

I use true ketogenic diets in patients who have a lot of inflammation. Beta HydroxyButyrate (BHOB) is a strong anti-inflammatory.1 It inhibits COX2, inhibits the NLRP-3 inflammasome, and activates AMPK. This can be really helpful for reducing pain in my patients and has been demonstrated in studies. It is also helpful for neurological conditions. The brain and the nervous system can function very well with ketones. Also, all nerves are surrounded by a membrane that is high in fat. The low-fat movement has led to deficiencies in essential fatty acids and can be problematic related to depression and other neurological conditions.

CD: I think there are a small number of people who can thrive on a high intake of animal protein and few vegetables, at least temporarily, but in my clinical experience, a diet like this results in problems down the road, particularly if it is high in processed meats or foods.

If we don't give our patients a plan they can follow, none of the details of it matter. I'm in the Midwest and will sometimes start the conversation with, "Do you like bacon?" and we go from there. My philosophy is to meet people where they are at. In the end, though, my patients end up often eating more vegetables than they have ever eaten in their lives. They start to cut the meat down themselves if they are checking ketones because too much protein makes it hard to stay in ketosis. I find this strategy helps me change the diets of a lot more people than if I was dogmatic about any one program. We also check in with how they are doing and use lab markers. If they are plateaued or struggling with something, we adjust. I emphasize avoiding most of the processed low-carb foods, and if they eat a low-carb processed food, I have them count the total carbs from those foods. For whole natural foods like broccoli, I have them count the net carbs (i.e., total carbs minus fiber).

CD: Of course, I don't recommend a type 1 diabetic do anything without consulting with their health care team. Fasting is actually sometimes a recommended practice to see if your basal (long-acting) insulin is right. You fast during the day, and if you have low blood sugar, your basal rate is too high and needs to be adjusted lower, either with long-acting insulin or by pump; you should not have low blood sugars. When a type 1 diabetic follows a low-carbohydrate diet, you take much less insulin and have much less likelihood of having high blood sugars related to food. When you use lower doses of insulin because of lower carbohydrate intake, you are less likely to have hypoglycemia. These episodes happen to all of us, but they are much less common and much easier to treat because you don't have a lot of insulin. I can say I have not had a problematic low blood sugar in several years with this approach

Yes, I keep glucose tablets with me. Anyone on insulin should have them on hand at all times. I don’t use food or juice to bring up my blood sugar because it will raise my blood sugar too high above my target, and I am working for small corrections. I will bring my blood sugar up with half or one tablet if I need to raise it a little bit. For people following a higher-carbohydrate diet, much more glucose is needed to correct a low blood sugar.

Since we are talking about ketones and type 1s, we should mention ketoacidosis. There is a difference between nutritional ketosis and ketoacidosis. Ketoacidosis is still possible in a type 1 diabetic, but in a well-formulated diet with normal blood sugars, it is actually incredibly rare and usually is the result of serious illness with dehydration.

One other thing that may also be a factor in it being easier for some in a well-formulated plant-based keto diet to get into ketosis is arginine. Arginine is an amino acid that stimulates insulin release and, in fact, can be used in laboratory testing to see how much the beta cells are still functioning. Foods that are higher in arginine tend to stimulate insulin release, and insulin drives down ketones. There is arginine in plant-based proteins but much less than in animal-based proteins. This is just a theory, but it makes sense in my mind. When we want to see if someone still has beta cells making insulin, we can give them IV glucagon (which makes them sick) or IV arginine (which has fewer side effects).

It might feel intimidating to get started, but start slowly and work your way up. Like with any lifestyle change, it’s important to listen to your body.