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Psychology of the Ketogenic Lifestyle . . .

Ketogenic Lifestyle – the Balance of Endocrinology & Psychology

Over the last few weeks, I’ve had the pleasure of talking to a number of patients and friends about what it means to live a ketogenic lifestyle.  A low-carbohydrate or ketogenic lifestyle is different from a low-carb diet. It is different because the definition of lifestyle implies the way a person lives their life that reflects specific attitudes and values, not just how they eat. My recent posts, The Principle Based Ketogenic Lifestyle – Part I and Ketogenic Principles – Part II, focus on fundamental principles making the ketogenic lifestyle one in which balance and grounding in all aspects of life can occur.  When the mind, the body or the spirit are out of balance or un-grounded, symptoms of metabolic inefficiency, sickness or disease result. 

I have been fascinated, as a family practitioner, that the body produces “warning flags,” when there is dysfunction in one of these areas: mind, body & spirit. These warning flags are byproducts of inefficient inter-related functionality between the body’s systems and it is one of the foundation principles of osteopathic medicine.  Prior to the advent of many of our diagnostic techniques today like MRI, CT scan, advanced laboratory evaluations, and ultrasound, these were the only indicators of disease that a physician could identify, and upon which diagnosis was made. These flags often show up on the skin, in the hair or nails, in the complexion, or in general appearance or mannerisms.

Skin tags
Skin Tags (fibroepitheial polyps) under the arm

For example,”skin tags” are now recognized as pathognomonic, specifically indicative, of insulin resistance and will often occur up to 20 years before impaired fasting glucose or diabetes is ever recognized.

exopthalmos 2
Exopthalmos (bulging or protruding of the eyes) from hyperthyroidism

Exopthalmos, or protrusion of the eyes, is pathognomonnic for overactive thyroid function (hyperthyroidism), and spider angiomas occur as a somatic flag that cirrhosis of the liver is present.

Alligator Skin (severe dry skin) found in hypothyroidism
Alligator Skin (severe dry skin) found in hypothyroidism

Hair loss and dry skin, or “alligator skin,” represents the exact opposite with an under-active thyroid (hypothyroidism).

Spider angioma seen with cirrhosis

When metabolic pathways get “clogged” or flow of blood, lymphatic fluid or hormones do not reach the destinations they were meant to reach, symptoms of accumulation or poor function begin to arise.

Anterior Chapman's Reflex Points
Anterior Chapman’s Reflex Points (images adapted from Osteopathic Foundations of Medicine.)

The osteopath is also trained to recognize a corollary Chapman’s Reflex Points that act as flags for dysfunction in specific organs or regions of the body. These points relate directly to what causes the pathognomonic flag.  I frequently identify abdominal, adrenal, pancreatic and liver Chapman’s points present in those with insulin resistance, inflammatory diseases, pre-diabetes and diabetes.  Understanding how to interpret and use these flags comprises four years of medical school and three to four years of residency and often years of clinical application.

Mental or spiritual pathways can often be bloc-aided by poor recognition of, or refusal to acknowledge, individual truths in our lives. Interestingly, the signs or warning flags of spiritual dysfunction are also expressed physically.

“Oh, no?! Dr. Nally are you going to get all religious on us?”


Over the last 15 years of my medical practice, I’ve witnessed the spiritual component of the “mind, body, spirit” unit, or lack thereof, have profound impact on the body’s ability to heal.  Every one of us must defeat what Sigmund Freud called the pleasure principle – the human instinct to seek pleasure and avoid pain, including recollections or memories that are painful.    Hiding from these memories because of pain is very common and is part of human nature.  We often believe that thinking about or re-living the truth may cause us individual overwhelming un-survivable grief.  So, we naturally bury the thoughts and emotions and feelings deep down into our subconscious minds.

In fact, we take irrational risks, busy ourselves, use food or drink for short term comfort and move from one distracting or debilitating relationship to another. We lose and then regain gain weight, become workaholics, hide behind thousands of texts, social media posts and emails in order to protect ourselves from the part of ourselves that we don’t want to think about.

However, when we step away from the distractions and courageously look at our individual history, our personal life story, honestly and completely, feelings of sadness, anxiety, regret and anger may often arise.  These painful emotions bring with them essential insights into how experiences will help you and I individually grow, become a better people, and help others along the path.  It takes faith to trust that these experiences will not destroy us, but were allowed to occur by a loving Father or Creator, understanding that for you and I to grow, we must each be given individual agency to chose.  It takes faith to recognize that that Father has your individual best interest in mind. Hiding from these emotions clogs the mental and spiritual systems and fuels disabling depression, anxiety, insomnia and fatigue. These feelings, real as they are, persist when there is no other physical sign of illness.  That’s because this illness is not physical.  It is spiritual. When we are out of line with the truths that bring peace and balance to our lives, negative, self-limiting patterns of activity and fear stifle growth and development mentally.

It is fascinating to me that on more than one occasion, as an osteopath, when a patient suffering from these symptoms gets a massage or has an osteopathic or chiropractic manipulative treatment, they may suddenly become tearful or have unexpected release of emotion. Physical treatment over the areas of congestion can, and do, cause a reflex triggering of mental, emotional or spiritual release of tensions.

How do I know that it is truth we are hiding from?  Take the words of the Buddhist teacher Sogyal Rinpoche found in The Tibetan Book of Living and Dying among many others throughout the ages:

“Saints and mystics throughout history have adorned their realizations with different names and given them different faces and interpretations, but what they are all fundamentally experiencing is the essential nature of the mind.  Christians and Jews call it “God”; Hindus call it “the Self,” “Shiva,” “Brahman,” and “Vishnu”; Sufi mystics name it “the Hidden Essence”; and the Buddhists call it “buddha nature.” At the heart of all religions is the certainty that there is a fundamental truth, and that this life is a sacred opportunity to evolve and realize that truth.”

Wait a minute, what does all this have to do with a ketogenic lifestyle?

The ketogenic lifestyle is one that is based on values.  A patient following a ketogenic diet recognizes that food has just as powerful effect on the hormones of the body as does prescription drugs.  Understanding the value of hormone balance and the principles that effect weight, inflammation, blood pressure and cholesterol, the ketogenic lifestyle is one in which carbohydrates are restricted in an individually tailored way to obtain the end goal. How does a ketogenic lifestyle balance mind and spirit?

Step One

Put down your force-field.  This takes courage and it takes faith.  Your force-field is any distraction that keeps you from thinking and feeling and identifying truth.  These include excessive alcohol, illicit drugs, binge eating, smoking, gambling, working excessively or getting lost in repetitive dramatic romantic relationships .

Believe me, the force-field gets heavier every day.  After my father passed away at age 58 from the major complications of diabetes and my sister committed suicide a few years later, I threw myself into work and church service.  I worked 16-18 hour days, completed a second board certification in Obesity Management and a fellowship in Health Policy, all while serving as a bishop and counselor in my church.  I found that I could raise my force-field of justification to hide from the pain and emotions of family illness and depression.

But the force-field saps your energy and cheats you out of seeing your full potential.  I found that as long as I held up my force-field (and some of us care more than one), I couldn’t see the experiences that made me who I am and connect me with those I was trying to serve and help.  As long as I was holding up my force-field, I was living in the fear of re-experiencing the pain of loss and the worry of future disease, . . . and people sense that.

You don’t have to drop the force-field all at once. You don’t have to quit work and become a hobbit. You just have to lower the field a little bit, enough to peek over and let the Eternal Truth shine on you. Truth is a funny and powerful thing.  The more we overcome our reluctance, face the pain and the fear, the more we realize just how often things begin to go well for us.  Living in the presence of great truth and eternal law and being guided by permanent values is what keeps a man patient when the world ignores him, and calm and unspoiled when the world praises him.

Step Two

Identify emotional or behavioral patterns that you want to change. If you don’t know, ask a trusted friend, your spouse, or your relatives. As I think back over the years, I had a couple trusted friends pull me aside and identify a few of those patterns face to face.  I appreciate that, and I’ve never forgotten it.

  1. Make a list of the events in your life that you regret and wish you would have made a different decision.
  2. Go over the list as many times as you need to to identify the pattern or theme that seems to tie the regrets together.
  3. Then actually write down the theme or reason that you identified as the cause. This allows you to identify and remove the corrupted soft-ware of your soul.
  4. This process can take time and is often camouflaged by denial.
  5. Major insight often comes as a knock on the door of denial, so listen carefully to what is being said.  Listen to yourself listening. Psychiatrists say that if something said while listening to a patient makes them suddenly feel sad or irritable, then that may be a meaningful theme in the patient’s life.  Listen to your gut feelings as you go through the day.  Don’t ignore a prompting from your soul.

Step Three –

Realize that today’s negative emotional and behavioral patterns are connected with painful memories and unsolved past conflicts.

Do you get a gut feeling that you want to change the subject when someone brings up a financial setback?  Do you want to reply with one liners like, “I’m sure it will all work out?”  Are there other topics that make you uncomfortable?  Ask yourself why that topic makes you uncomfortable . . . seriously, ask yourself, and then answer yourself.  Do you suspect your spouse of cheating when there is no objective evidence to support the suspicions?  Recognize these uncomfortable feelings are our subconscious waving flags to make us each aware of unresolved conflicts within our mind and spirit.

Remember, we attract the type of energy we give off.

Step Four

Pray to whatever higher power you believe in.  Meditation, prayer and “ponderizing” brings a reservoir of faith and courage to find and to face the truth.  If you have the faith, get on your knees and sincerely ask God for help facing your truth and the challenges, fears and sadness that reflecting upon it may initially bring. I promise you that you will gain the strength to accomplish the task. It will bring the strength to overcome the hidden trauma in your earlier life and will give you the strength to resist the call of ice cream at 3 am.

d_day_courageFollowing these four simple steps, keeps you vigilant to the physical and spiritual warning flags that may arise on your ketogenic journey and will bring great confidence while modifying your diet to balance your body’s hormonal milieu.  Confidence inspires courage.  Those with courage and confidence in themselves, and faith that they are on the right path, are unstoppable. Good luck . . . I look forward to seeing you on my journey down the same path.

Ketogenic Principles . . . Part II

There are three constants in life: change, choice & principles.   Change, ironically acting as a constant, is the variable that we have limited control over.  Accepting that change is going to happen, that change is constant, and making choices to prepare for those changes is the key to success.  My last post introduced the 10 Principles of the Ketogenic Lifestyle.  This post will discuss choice as a foundation for those principles outlined in the ketogenic lifestyle.  Choices are directly influenced by the balance between the mind, the body and the spirit of man.


People seem to get sidetracked off a ketogenic lifestyle for a number of reasons, but the most common I hear is that they were traveling, had company visit or they were on vacation.  Successfully living a lifestyle requires that you first know who you are and where you are before you can consistently make good, solid, principle based choices. So I ask, who are you?  Are you defined by your job, by your finances, by your travels, by your friends or by your vacations?  Each of these experiences is unique.  Our experiences place both good and bad before us.  I have come to learn over time and countless interactions with people that nothing is coincidental.  Everything, good and bad, happen for a reason.

Today’s society teaches the Pleasure Principle.  This is the human instinct to seek pleasure and avoid pain, including avoiding painful recollections.  We often define ourselves by those things that bring us pleasure.  We each go through personal tests, failures and triumphs. Some of us harness all of those experiences for good, others find worsening mental paralysis due to fear of them. We often hide from the painful experiences and attempt to bury or forget them.  Food is often involved with many of the experiences of life, and for a significant number of people, the endorphin release from eating a meal, sometimes just the act of chewing, may be the only pleasure one experience in a day, in a week or a in a year. Many people hide from painful recollections behind the simple pleasure produced by the eating of “comfort foods.”  Food, and our opportunities to experience pleasure from it’s various flavors, textures and physical stimulus, begin to define us.  However, hiding from life’s painful memories with momentary pleasures usually prolongs or makes the problem worse. The ingestion of simple foods containing glucose and fructose, their effect on the liver, and the hedonistic hormonal response is the basis of addiction, and simple carbohydrates provide the perfect fix.

weight watchers diet pillsFascinatingly, when fructose is metabolized in the liver, in the presence of glucose (the basic structure of sugar – one fructose molecule bound to a glucose molecule), the byproduct has a hedonic (pleasure experiencing) effect on the exact same pleasure receptors in the brain that bind to morphine.   Yes, that’s why the M&M’s make you forget your troubles and why the Jolly Rancher is so jolly.  And, its the same reason you crave another do-nut two hours after you ate the entire baker’s dozen.

Although obesity has been recognized as a disease, our use of foods to celebrate with people or events in life is still a form of pleasure seeking. Excuses to deviate from healthy behavior under the guise of family, vacation, or social requirements, acknowledges our willingness to hide from pain with hedonic drugs like chocolate chip cookies and cotton candy.  In fact, it’s usually a welcomed and and expected acceptable excuse.

“Dr. Nally, I can cheat eat and bad, (meals loaded with starch) because I’m on vacation” . . . from my problems.  It’s so acceptable, we’ve based movie themes around it. Vacation from your problems

Healing can only occur when one is willing to confront and talk about the reasons, the real reasons you’d rather experience the endorphins from the do-nuts with your family instead of acknowledge your weakness, stresses, and fears.  Many of us are so afraid of where we might be, we avoid acknowledging where and who we are.  It takes courage not to take the easy path.  And I will be the first to admit, pizza is the easy path and it’s scenic views are decorated with french fry palms and sunset clouds of apple fritters.

“There appears to be a conscience in mankind which severely punishes the man who does not somehow and at some time, at whatever cost to his pride, cease to defend and assert himself, and instead confess himself fallible and human. Until he can do this, an impenetrable wall shuts him out from the living experience of feeling himself a man among men.  Here we find a key to the great significance of true, un-stereotyped confession – a significance known in all the initiation and mystery cults of the ancient world, as is shown by a saying from the Greek mysteries: “Give up what thou hast, and thou will receive.” (Carl Jung)

We have a choice about what to eat and when to eat, however, each choice has a reward and/or a consequence.

Points of Focus: Where are you and what are you hiding from?  Sharing your weaknesses actually empowers you you overcome them. This can often be accomplished through the simple act of journaling, planing your meals the day before and journaling your successes and failures in that plan the following day.  Allowing yourself and others insight into your times of weakness actually brings strength.  It allows one to look at the reasons for food choices base on how you feel, and how you felt after the choice.  If forces one to think about a choice before it ever has to be made.  In my 15 years of medical practice, I have yet to hear a child find fault with a parent who worked tirelessly to make ends meet, admittedly struggled with alcoholism, battled against disease or fought against belittling for a belief. The child has always expressed their admiration of their parent’s courage and understanding of why decisions were made, even when erroneous. It takes courage to admit that wherever you go – there you are.


Keep it realI no longer believe in coincidence.  Whether you have thought about it or not, every interaction you have with others (even our interaction . . . your reading this blog), are not by coincidence. There is a reason.  Whether you believe it or not, everything around us testifies that God exists; the Hand of Providence can be seen from the rotation of the earth, planets and stars, the precision of the seasons, the balance of the atmosphere allowing for the perfect pressures and concentration of elements to sustain a life giving breath, to the perfect replication of DNA within billions of cells throughout the body.  I’m not trying to get religious, and, no, I can’t prove this through the scientific method . . . But, if the Big Bang started the universe, what started the Big Bang?  Where did the first atom or molecule or particle of dust come from?  I have a very difficult time accepting that you and I are here by accident, by a chaotic explosion that created order.  That implies that there must be a plan, and that plan had to have been set in motion by a Creator.  That also implies that that Creator placed solutions to our challenges, including the diseases of civilization, within our grasp and available to those seeking the solutions upon the earth today.

I have seen enough in my medical career to know that simple coincidence has frequently become significantly important, life changing and often life saving. This does not happen by accident and screams loud and clear that there is a plan for you and me.  No good father would lock his child in a room without doors or windows or any escape without everything in the room, both good and bad, pointing to the reason the child was in the room, and pointing the way for the child to become his or her best self, physically and emotionally.  Life has meaning. It is supposed to. If we get off track, coincidence and interactions lead us back.

“Behold, the hour cometh, yea, is now come, that ye shall be scattered, every man to his own, and shall leave me alone: and yet I am not alone because the Father is with me.” (John 16:32)

The Bible, among other records, records the voices of men and women from years past transcribing their experiences with the Hand of Providence, how that spiritual void was filled, how it helped the with choice and how our lives have deeper meaning and consequence, even amidst significant adversity.

Take a week and look at the synchronicity of your life.  Journal about it.  Don’t dismiss a second invitation from someone to discuss an opportunity or meet someone your friend thinks could be important to you, open that book that someone left behind on the subway seat beside you. Don’t assume it is meaningless, that some kind person returned your sunglasses or your wallet.   Look at the simple interactions and recent relationships.  These are the breadcrumbs and the street signs from a loving Creator, a loving Father.

Keeping it real means nothing less than complete authenticity.  The last place you want to be is in the first-class seat on the plane to no-where.  Have the faith to get off the plane and take the bus, ride your bike, or even swim upstream in the direction you’re supposed to be going. Look for the coincidences, bread crumbs and spiritual street signs in your life.

How does this relate to a ketogenic lifestyle?  Every religion or spiritual tradition speaks of a polestar.  The polestar is that anchor to which the entire solar system is tied by invisible aerial chords and the engine that powers the universe.  Those cords are connected with our own individual polestars.  A ketogenic lifestyle is one that encompasses mind, body and spirit.  It is a lifestyle that demands that you link and align your personal polestar with the truth inside and around you.  It takes both courage and faith, but it brings immeasurable strength and help in achieving your goals.  A person out of balance with life is under stress.  Chronic stress produces excessive cortisol and other powerful adrenal hormones that displace the body’s and the mind’s endocrinologic balance, leading to weight gain, weight retention, and chronic disease.  This often has significant effect externally on the body in processes seen like depression, anxiety, fibromyalgia, and allowing for amplification of inflammation and auto-immune dysfunction.  We refer to this inter-relationship in the medical community as psychosomatic and/or viscerosomatic dysfunction, the psyche (the mind) and/or the viscera (internal endocrine organs) directly and adversely influence the function of the soma (the structural body separate from the mind).

“He who does not know himself, does not know anything, but he who knows himself, knows the depth of all things. 

” . . . If you bring forth what is within you, what you bring forth will save you. If you do not bring forth what is within you, what you do not bring forth will destroy you.”  (Book of Thomas the Contender)

Point of Focus: Your life is never without meaning. Keep it real by recognizing that diet alone may not compete your answer for physical health.  Having courage and faith allow you to see and embrace the truth that is right in front of you. The  Alcoholics Anonymous’ 12 step program only becomes successful when one realistically and courageously applies their faith to align with the truth they have felt all along.  For any long-term lifestyle change to take place, one must connect and live the principles before one truly knows they are true.  In this way the Ketogenic Lifestyle becomes real.

KetoOS – Drinkable Exogenous Ketones

LIFESTYLE PRINCIPLE 3 – TO cheat, or NOT to cheat, that is the question

cheat mealI have been asked this question by every patient I have placed on a ketogenic diet at least once and often three or four times throughout the course of our treatment plan. I usually answer this question with a question. “Why do you want to cheat?”

The desire to cheat usually arises form one of three reasons:

  1. You’re not eating enough fat to satiate your appetite and you are truly hungry.  The body recognizes that it can use and absorb glucose much faster than fat, as fuel, so it naturally will crave “sweets.”  In this case, the case of true hunger, solution is to increase your fat intake.  You should be eating at least 50% of your total calories in the form of fat.
  2. Insulin loads are still high, stimulating rebound hunger and hedonistic cravings. You’re either eating too many carbohydrates with your diet or you’re using a sweetener that stimulates insulin without raising blood sugar  (See my article The Skinny about Sweeteners).
  3. Cheating with a specific food fulfills a psychological need, feeds an addiction or represents an obligation to fulfill a societal ritual. Journaling helps to identify and break this cycle.

If you are truly in ketosis the cravings to cheat don’t exist, they actually disappear.  Other societal rituals, like birthdays, anniversaries, weddings, spiritual ceremonies or rites of passage are often tied to or use food as symbolism.  In these cases, the decision to cheat is really yours.

When a person cheats, it can take as many as 3-5 days to get back into ketosis, and for some 2-3 weeks.  Carbohydrate cravings will rebound and often be present for up to 72 hours after cheating. You have to decide if cheating is worth 3 days of carbohydrate cravings and 3-7 days of stifled weight loss.

Point of Focus: There are no Ketosis Police! Really. They don’t exist!  Dr. Nally will not show up in uniform on your doorstep with a set of handcuffs and a bag of pork rinds. You won’t be arrested for eating bread and those of us who have been following a strict ketogenic lifestyle for years really don don’t mind at all if you decide to cheat.  We will smile and we may even ask you how it tastes or if you liked the flavor, but don’t be self-conscious, because when one is in ketosis for a few months, we really don’t crave cheating any longer, and we won’t judge you. And, don’t feel obligated to justify why your cheating, this is a lifestyle.  You probably won’t ask me why I chose to wear long sleeves on a hot day in Arizona, for the same reason I won’t ask you why you decided to wear a Speedo.

LIFESTYLE PRINCIPLE 4 – Hunger Management

Man-vs-Shark_11Life comes at you pretty fast and if you’re not prepared, hunger can bite you.  Most people fall off the wagon when they are unprepared for missing a meal on a stressful day. I’ve recently heard the argument that “there is no wagon, so don’t worry about falling off.”  This is false security that leaves one unprepared for life events.  Pioneers traveled in wagons for two reasons.   First, the wagon held supplies essential for survival.  Second, wagons usually traveled in wagon trains.  This means that there was more than one person on the wagon and there was more than one wagon on the trail with you. Traveling with a wagon train meant you had others on the same trail with the same tools for safety and support.

In the world of fast foot, fast photos and speedy delivery, we often don’t adequately prepare for hunger or cravings.  There are some essential hunger management tools for the Ketogenic Lifestyle:

  1. Eat meals containing >50% fat.  This, in and of itself, delays hunger and ensures the satiety center of the brain is happy for longer periods of time.
  2. Carry rescue foods with you or keep them at your office or in your fridge at home. These include low-carb nuts like almonds, walnuts, macadamia nuts; Keep hard and string cheese handy for a snack.  Use sliced deli-meats with the cheese as a snack when the cravings kick in.  Pork Rinds, beef jerky, olives, are great natural food options.
  3. If you have time and can cook, develop your favorite “Fat Bombs and have a bag full in the fridge for those cravings.
  4. Having the moral support of a buddy, spouse, friend or work companion who checks on your progress daily, assists with meals and meal choices is priceless. Periscope, a free Twitter based App, has become a means of checking in with your Ketogenic Support group around the world that connects to those you follow on Twitter.  You can follow me, @docmuscles, and a number of fascinating health Periscopes that focus on ketogenic, low-carb, whole food paleo approaches:  @livinlowcarbman, @_danielleeaton, @kasandrinos, @fatissmartfuel, @domskitchen, @mikemutzel, @keribrewster, @tombilyeu, @glutenfreenj, @paleocomfort.
  5. Being accountable to yourself in a diet journal daily and to your doctor regularly every 1-2 months also helps keep motivation going forward. Jimmy Moore, author and podcaster at the Livin’ La Vida Low-Carb Show has also posted one of the most extensive lists of physicians specializing in ketogenic diets from around the world.  You can find that list here.

LIFESTYLE PRINCIPLE 5 – Stress Reduction

Pages and pages can be written about stress reduction.  In fact, I’ve written about the chemical responses that stress has on weight gain in my post, Stress. . . The Weight Loss Killer.  But there are a few daily essentials that should be added into the Ketogenic Lifestyle to manage stress.

First, are you getting adequate sleep? Remove the television, computer, cell phone, iPad or other electronic distraction from the bedroom.  Go to bed at the same time and get up at the same time each day. Give yourself time each day away from being plugged in, logged in or on-line.

Second, over exercising or being malnourished can cause chronic stress. I have a number of patient that have been convinced that they have to work out 60 minutes a day 6-7 days per week.  It is essential that you realize muscles need a minimum of 48-72 hours to recover from specific types of exercise.  If you run for 60 minutes.  It will take your muscles 48 hours to recover from the running. If you do upper body weight lifting, it will take 48-72 hours for those muscles to recover from that weight lifting.  Exercising the same muscle group with the same exercise over stresses the muscles and leads to significant chronic stress, spiking the cortisol levels and halting weight loss and raising cholesterol & triglycerides.  Under eating or fasting to starvation has the same effect.

Third,  mild intensity (40% of your maximal exertion level) exercise 2-3 days a week was found in a recent study to lower cortisol and decrease over-all stress, raising serotonin and dopamine in the brain; however, moderate intensity (60% of your maximal exertion level) to high intensity (80% of your maximal exertion level) exercise was found to raise it.  A simple 20 minute walk, 2-3 times per week is very effective at stress reduction, reduction in cortisol and improvement in ketosis.

Point of Focus: The goal is cortisol reduction. This can be done through regular and restful sleep and mild exercise. Chronic elevation in cortisol directly stimulates an increase in insulin by increasing the production of glucose in the body, and cortisol blockaids the thyroid axis. Both of these actions halt the ability to loose weight, amplifies the production of inflammatory hormones and drives weight gain. Cortisol also increases appetite.  That’s why many people get significant food cravings when they are under stress (“stress eaters”). Cortisol also indirectly affects the other neuro-hormones of the brain including CRH (corticotrophin releasing hormone), leptin, and neuropeptide Y (NPY). High levels of NPY and CRH and reduced levels of leptin have also been shown to stimulate appetite.

Hopefully, this gives you some starting points and direction to your Ketogenic Lifestyle.  If I’ve missed something that you’ve found to be essential, let me know. Its always great to hear what has helped you in your Ketogenic journey.  Until next time, pass the butter!!!

Nutritional Values of Commonly Used Ketogenic Foods

I’ve had a number of emails and requests from patient’s to locate a source for fat percentages and protein contents of various foods as they prepare and follow a ketogenic lifestyle.  I’ve looked all over, however, nothing easy and concise has made itself readily available, and there hasn’t been a simple one page tool at your fingertips . . .

Hopefully, this list will start to fill that gap.  Use the list to calculate protein and fat levels as needed.  Let me know if I can add to the list or if there are foods you commonly use that I’ve missed.  Keep the ketones up and your waistline down!

Nutritional Values of Common Ketogenic Foods:

Food:                                                                       Protein Contents:                                Fat Contents:

Steak (Ribeye) –                                                      65 grams per 8 oz.                                 49%

Steak (Top or Bottom Round) –                             23 grams per 3 oz.                                  33%

Ground Beef (75% Lean) –                                      22 grams per 3 oz.                                 55%

Pork Chop (boneless) –                                            26 grams per 3 oz.                                15%

Ham –                                                                      17 grams per 3.5 oz.                              12%

Bacon (grilled) –                                                      22 grams per 3.5 oz.                               75%

Sausage (beef) –                                                     14 grams per 3.5 oz.                              79%

Sausage (pork) –                                                     17 grams per 3.5 oz.                              75%

Chicken Breast (boneless, skinless) –                     24 grams per 3 oz.                                  18%

Turkey Breast –                                                       24 grams per 3 oz.                                  15%

Yellowfin Tuna –                                                     25 grams per 3 oz.                                  10%

Light Tuna –                                                             22 grams per 3 oz.                                 8%

Halibut –                                                                  23 grams per 3 oz.                                  19%

Sockeye Salmon –                                                   23 grams per 3 oz.                                  22%

Tilapia –                                                                   21 grams per 3 oz.                                  13%

Deli Meats:

Roast Beef –                                                            18 grams per 3 oz.                                  16%

Canadian bacon –                                                    15 grams per 3 oz.                                  33%

Pepperoni –                                                             18 grams per 3 oz.                                  83%

Roast Turkey Breast –                                             18 grams per 3 oz.                                  15%


Beef Jerky (Jack Links) –                                          13 grams per 1 oz.                                9%

Peanut Butter (Peter Pan Crunchy) –                      8 grams per 2 tbsp.                                76%

Mixed Nuts –                                                           6 grams per 2 oz.                                    79%

Almonds, raw –                                                       6 grams per 1 oz.                                    66%

Walnuts, raw –                                                        4 grams per 1 oz.                                    85%

Sunflower seeds, raw –                                          6 grams per 1 oz.                                    76%

Tofu –                                                                      12 grams per 3 oz.                                  30%

Greek Yogurt –                                                        23 grams per 8 oz.                                  0%


Swiss Cheese –                                                        24 grams per 3 oz.                                  66%

Cream Cheese –                                                      11 grams per 3.5 oz.                               79%

Ricotta cheese –                                                      10 grams per 3.5 oz.                               63%

Cheddar cheese –                                                    24.6 grams per 3.5 oz.                            74%

Eggs –                                                                      6 grams per 1 large egg                         60%

(Adapted from http://www.caloriecount.com)

A printable PDF copy of this information is available here:

Nutritional Value of Common Foods.

To live in the presence of great truths and eternal laws, to be led by permanent ideals –  that is what keeps a man patient when the world ignores him, and calm and unspoiled when the world praises him.  Hopefully, these posts are adding to your stable ideals.

The Principle Based Ketogenic Lifestyle . . . Part I

BalanceIt has been resoundingly clear to me over the last couple of weeks that there is a tremendous need for a principle based approach to a ketogenic diet.  This approach, however, must be simple.  So many of the approaches to weight loss I read about are complex and the questions that arise from these approaches are innumerable.  Losing weight should not be as difficult as putting a man on the moon.  To quote a patient recently, “If it ain’t simple, Doc, I ain’t doing it. . .”

I agree.

Any approach that requires the conversion of food to numbers or calories or exchanges becomes cumbersome, and I personally won’t follow it for more than a week.   The principle based approach should be simple and is really based upon the mantra:

Give a man a fish and he will eat today. Teach a man to fish and he will eat for the rest of his life. 

Ketogenic diets are wrongly referred to as diets.  What I’m talking about is a ketogenic lifestyle.  Simple lifestyle design should not be hard. So, what do you say? Shall we learn to fish?!

I assume that if you’re reading this article, you already understand that weight gain is not due to an over intake of calories.   Weight gain is due to hormone signals throughout the body leading to the storage of fat . . . specifically, triglycerides being taken up into the fat cells.  The hormone that independently controls uptake of fat into each fat cell is insulin.  Insulin is an essential hormone, but too much of it stimulates the adipose (fat cells) to over-stock triglycerides or essentially “get fat.”  It, actually, is that simple.  There’s really only one rule to this lifestyle: If it raises your insulin it will halt or stall your weight loss.  Write that on your hand or your forehead or in your planner, the lifestyle revolves around that one rule.

Most people start a ketogenic diet because they want to lose weight and have failed at multiple other dietary approaches. Reasons for weight control failure are often multi-faceted, but they all start with from a position of flawed understanding. The majority of approaches to weight management come from  the false assumption that weight is gained because of an over-consumption of calories or a lack of physical activity to burn excess calories.   People have faithfully been restricting calories and exercising to exhaustion since the early 1980’s to no avail. (Well, 1% of people succeed, but the rest of us failed this approach). The definition of insanity is repetitive completion of an ineffective action and expecting a different outcome each subsequent time around. If you still think that caloric restriction and exercise is successful, I’ll be shipping your drawstring white vest and your invitation to a padded cell shortly.

Let me put it clearly.  We’ve been exercising and cutting our calories since 1975 and look at what it’s gotten us . . .

Obesity Trends 2015

. . . . a country that is now recognized as the “United States of Corpulence.”  Super-Size me has become literal. “Houston . . . we have a problem . . . !”


The rule above is based on foundational principles.  Understanding of the principles allows one to successfully apply the rule above.


The first principle in a ketogenic lifestyle is understanding that the problem is not caloric, but hormonal.  Choices and actions from here on out must be based on this understanding.  Anything that will raise insulin will thwart ketosis. Insulin stimulates lipoprotein lipase, the enzyme that pulls the triglycerides into the fat cells. Without insulin, we don’t gain weight. (That’s why type I diabetes are usually very slender and skinny).

The standard lab value for normal fasting insulin levels reflect 10-22 uIU/L as the normal.  However, in my office, glucose tolerance tests and postprandial glucose tests consistent with impaired fasting glucose are routinely positive when the fasting insulin level is >5 uIU/L.

Point of Focus: If your having trouble, look at the hormones.  Food stimulates hormone responses. Focus on the hormone response to your diet.


A ketogenic diet is one where the body uses fatty acids as the primary fuel. Those triglycerides mentioned above are made up of three fatty acids linked to a glycerol molecule.  To use the triglycerides, the three fatty acids must be broken away from the glycerol by hormone senstive lipase (HSL).  Insulin directly inhibits HSL. Keeping insulin levels low is the first step in shifting to a ketogenic metabolism. Lowering insulin allows access to the fatty acids in your fat cells.  Triclycerides are not water soluble and the rate by which they can be taken up and burned in the mitochondria limits the speed by which triglycerides can be used as fuel. The by product of triglyceride burning is ketones.  Ketones themselves can be used as fuel and over 4-6 weeks, the body can enhance its ability to use ketones when fat is the primary fuel. This is called “Keto-Adaptation.”

Point of Focus: Too much carbohydrate or too much protein in the diet shifts the body from the use of triglycerides.  In general, to become “keto-adapted,” limit carbohydrate to < 20 grams per day.  Keep protein < 1.0 grams per kilogram of ideal body weight for women and <1.5 grams per kilogram of ideal body weight for men.

KetoOS – Drinkable Exogenous Ketones


Wait a minute!? Where do the ketones come in? When fatty acids are burned or oxidized in the mitochondria of cells within the liver, they are converted into Acetyl-CoA.  The Acetyl-CoA is used to form ATP for energy in the Citric Acid Cycle.

Metabolism macronutrients

IF excess Acetyl-CoA production occurs or if inadequate oxaloacetate is present, the extra Acetyl-CoA is transformed into ketone bodies – specifically beta-hydroxybutyric acid and acetoacetic acid.  Fat can be oxidized or burned for fuel while ketones are being produced.  Ketones are much smaller molecules and can more easily be transported in the blood than triglycerides, as they are water soluble. The ketones themselves can also be used or burned as fuel as the body upregulates the mitochondria’s ability to use the ketones as fuel as well.  As I mentioned above, this process of “keto-adaptation” can take 4-6 weeks. Keto-adaptation results in humans having a greater desire to be physically active – the miraculous conversion of the couch-potato into the bacon-burning triathlete.

Point of Focus: Sugar is a drug.  Its byproduct has the same hedonic effect on the brain as morphine.  Sugar withdrawal can commonly cause headache, anxiousness, insomnia, dizziness, fatigue and moodiness within the first week of carbohydrate restriction on the road to keto-adaptation.



For the average person to become “ketotic” or reach a state of ketosis, it takes lowering the carbohydrates to less than 20 grams per day (and sometimes less than 10 grams per day) for at least 3-7 days.  Yes, it can actually take a week to reach ketosis.  I have a few patient’s that are so insulin resistant that it takes longer.  This means that to reach that fat burning state, one must maintain a low insulin response by restricting starch or carbohydrate intake to less than 20 grams per day for a minimum of a week.  For your body to efficiently use the fuel it can take up to 6 weeks.  This is why many people state that they “don’t feel good” or “can’t maintain their exercise levels” when starting a ketogenic diet. For most people, once they reach the 6 week mark, mitochondria have been unregulated and “fine tuned” to burn ketones, fat burning becomes efficient and energy levels begin to increase. In fact, for many like myself, you’ll finally feel like exercising for the first time in you life.

Point of Focus: If you’re already exercising, don’t be surprised if you feel more sluggish for the first four weeks.  If you’re not exercising, I don’t recommend starting until after you pass through the Keto-Adaptive phase.

MIchelin Tire Man Pondering


Clinically, the average patient in my office will lose 5-15 lbs each month for the first three months. Then the weight loss will slow to 2-5 lbs per month. However, 1/2-1 inch continues to disappear off the waist circumference measurement every month.  THIS IS NORMAL. Continued weight loss of 15 lbs a month will leave you looking like the Michelin Tire Man – rolls of skin without fat. The body slows the weight loss to keep up with skin and connective tissue remodeling.  As long as ketosis is maintained, the fat will continue to melt away.  At this point, I’m not so worried about scale weight as I am your waist circumference.

Point of Focus: Successful ketosis does not always affect the scale, but usually causes your pants to fall down.


It has been my experience that it takes about 18 months for the average patient to reverse the insulin resistance while following a carbohydrate-restricted, high-fat ketogenic lifestyle.  There is no quick fix for this. If there was, I’d be sitting on a beautiful beach in the Caribbean.

Point of Focus: The Ketogenic dietary lifestyle is actually the antidote to insulin resistance, diabetes and the diseases of civilization.


Improvement in insulin resistance has also been demonstrated with mild to moderate intensity resistance exercise.  Moderate intensity resistance exercise is 20-30 minutes of exercise like walking, easy jogging, cycling, lifting weights, yoga or Pilates with speeds or weight heavy enough to break a sweat, but not so fast or heavy that you cannot carry on a conversation with your exercise partner.  Exercise improves insulin resistance – BUT IT DOESN’T CAUSE WEIGHT LOSS!  Yes, I know, Jack LaLanne just rolled over in his grave.  But, let me say that again.  Exercise improves insulin resistance, but it does not improve weight loss!! The three largest and most intensive studies of exercise involving over 67,000 people demonstrate that you can exercise till the cows come home and you’ll average about 1% weight loss.  If you exercise, realize it WILL make you hungry.  Eating the wrong food (carbohydrate containing foods) will stimulate insulin release causing your exercise to be fruitless (Actually, your diet should be “fruit-less” anyway)

Point of Focus: Exercise because you feel like it, it improves insulin sensitivity and it decreases stress, not for weight loss.


If you are eating enough fat, you won’t be hungry. Although this doesn’t always hold true in the case of patient’s with lepin resistance.  40-60% of patients with insuiln resistance have a concomitant leptin resistance (see the article on lepin resistance here).  A ketogenic diet is one in which 50% or more of total calories come from fat.  No, you don’t have to count calories, just pick foods that contain 45% fat or more.  Look for grass fed products as they will be higher in Omega 3 fatty acids.  Red meat is 55% fat. Pork is 45% fat. This is where the chicken salad or turkey wrap fails (see Why Does Your Chicken Salad Stop Weight Loss).  Look for alternatives to replace your basic meals and snacks.  If you love chips, try pork rinds or make chips from fried cheese or pepperoni.  Guacamole is a great replacement for bean dip.

Point of Focus: There is no need to eat 3-6 times per day.  As you increase the fat in your diet you will feel more full.  Eat when you are hungry, whether that is 3 times a day or once day, listen to your body.

Adapt Your Life


I’ve been following a ketogenic diet for over 10 years.  The most common complaint I hear is,  “Dr. Nally, I’m tired of eating eggs.”  Ketogenic diets don’t have to be boring. There are hundreds of resources on the web for spicing up your ketogenic diet. See the Recommended Sites page above for some ideas to start. The Ketogenic Cookbook by Jimmy Moore and Maria Emmerich is a recent edition to the literature and a fantastic resource. Check out Franziska Spritzler’s Low Carb Dietitian website and new book as well. If you live in the UK, you should see Emily Maguire’s website and blog.  She just completed a world tour, sampling all the low carbohydrate foods and restaurants around the world.  If you are a picture person, check out the Best Keto Meals of 2015 pintrest page followed by almost 16,000 people.  If you haven’t takent the time, you should visit Dr. Andreas Eenfeldt’s website.  He is one of Sweden’s premier ketogenic doctors has an immense number of resources at his website, Diet Doctor.  Finding someone that can help you fine tune your diet is also essential.  You can find a list of doctors that use ketogenic diets here.

Point of Focus: This lifestyle will require you to use real, whole food and cook like your grandmother or great grandmother did in the past.  Unfortunately, we’ve lost a great deal of the art of cooking that needs to be re-discovered. If your lifestyle is too busy to cook and prepare real food, that busyness is probably causing you stress, another culprit in the weight gain cycle.  The truth will set you free, but it will probably make you miserable first.


WARNING!  A very sweet patient of mine was given these instructions to treat her weight and blood sugar abnormalities.  She applied these principles and they worked marvelously.  She called me a few weeks later, however, mad as a wet hen.  She placed her husband (not my patient at the time) on the same dietary changes.  Her husband, who had significant blood pressure problems and was on four different blood pressure medications I later found out, had a sudden drop in his blood pressure and passed out.  As happens to many of my patients, blood pressure, ejection fraction of the heart and blood sugars quickly begin to normalize.  However, he never saw his doctor and never had is blood pressure medications adjusted.  Because of the normalization that can occur in as rapidly as 1-2 weeks, the medications became much too strong, he passed out and ended up in the emergency room. These dietary principles are effective. They are often just as powerful as a number of the medications that we routinely prescribe.

Point of Focus: Please see your doctor before beginning any of these dietary recommendations, especially if you have any underlying medical conditions including Hypertension, Diabetes, Congestive Heart Failure, Coronary Artery Disease, Gout, Kidney Stones, etc., please do not try the dietary changes alone.  Find a physician trained in the use of this type of dietary lifestyle in combination with close monitoring of your blood pressure, blood sugar and other key vital signs.

Stay tuned for Ketogenic Principles . . . Part II in the series where we’ll address Food Psychology, To Cheat or Not to Cheat, and Keeping it Real . . .