Replies

• May want to consider a workup for type 1/LADA. In my clinic the docs and/or I will usually order the following labs: C peptide, GADA, islet cell antibodies, and zinc transporter 8 antibody.
  April 9, 2024

• Sorry, this got stuck in the pending folder. Maybe we can still learn something from it.
  April 9, 2024

• I heard an interview on YouTube with Dr. Eric Westman, MD; said he had seen a couple patients who would have one meal with carbs and it could kick them out of ketosis for 2 weeks. https://www.youtube.com/live/sIhyWBAglcY Start at 48:39 Perhaps this is the case for your patient. They may benefit from the carnivore diet for a time, and then they can consider going back to keto after their bodies have healed.
  April 9, 2024

• Hello Jarrett Hammer, You offer many different variables over many patients that are having difficulty. Ill offer a perspective: I do things in 2 phases: 1) working on metabolic metrics first, then 2) focusing on weight loss. In this way, for part one, I am concerned about "what they are eating" and not "how much they are eating" In part one, its a focus on the foods associated with leaning into low carb then keto. The metric I focus on is triglycerides (55 to 70 target) They are a good "summary metric". For example, see page 38 https://drive.google.com/file/d/12Sj43XyeykdFsLePXaOX3_plFiBwNLBo/view?usp=sharing You can also find that the TyG index will indicate: - This TyG index value is NOT suggestive of insulin resistance. - This TyG index value indicates NAFLD diagnosis is unlikely. https://www.mdapp.co/tyg-index-calculator-359/ One they are eating the favorable foods to achieve metabolic health, phase 2 begins which is calories in-calories out (the amount they eat). This could be greatly affected by "metabolic adaptation" (lowered metabolism) from poor diet in the past - setting the calorie/portion sizes can be difficult because of this - its an experiment of lowering fat consumption until weight loss begins (this is predicated on carbs being low enough and that was nailed down in part one by watching the triglyceride metric - to hit that metric, carbs have to be low). I am very interested in obtaining a device for indirect calorimetry for this purpose (can help with evaluating thyroid med effectiveness, or metabolic diseases also) and have been considering this device https://breezing.com/ A little in the first phase depending on how the patients adoption of new things is going and foundational in the second is the resistance training Pam Devine mentions above. Muscle is key to regulating glucose and in some cases (like having dominant neanderthal genes) is essential for weight loss. Maybe this helps break the elephant down into some manageable pieces. Best, Brad
  April 3, 2024

• Why don't you do IF for teens with IR?
  April 3, 2024

• Hi Steven. I've been trying to catalogue papers etc that I find. I know one MD in this space, can't recall who, told me that in his experience, African Americans suffer the consequences of insulin resistance at lower A1C, lower fasting glucose, etc than whites and are more carbohydrate intolerant. For myself, I felt like I had diabetes symptoms at A1C of 6.1% which my doctor said was a perfectly fine A1c and not to worry about it. Certainly AA have greater issue with hypertension as well as I think response to blood pressure lowering medications. Here are a few snippets I've jotted down but haven't had time to fully process. Lp(a) concentrations are elevated in Blacks compared to their White and East Asian counterparts; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087179/#:~:text=Lp(a)%20concentrations%20are%20elevated,%2D79%20nmol%2FL)%2C https://www.jacc.org/doi/10.1016/j.jacc.2022.09.027 HDL not indicative of CVD in blacks.
  March 5, 2024

• I agree with above that it takes longer than one month to become fat-adapted for many patients and for results to show both physically and via labs. After getting fat-adapted, you can look at intermittent fasting or eating windows to improve insulin sensitivity. I treat teens with IR, so don't do IF, but have written an article published in KevinMD about when to use IF. IR is also very genetic. I also find the duration of the Insulin Resistance cycle is important and may require more than nutrition. Dialing in on all metabolic health strategies is helpful as mentioned above. If long-standing can be a tough cycle to crack. Are there other improvements physically? Waist circumference decreasing, less glycemic variability, less binging and craving, more energy? Noticing these improvements is so helpful for patients to believe they are getting traction. I consider medications too as part of the treatment. A little metformin can go a long way. Hope this helps! Karla Lester, M.D.
  January 6, 2024

• I have seen this as well. Are you checking fasting c-peptide as well - it represents about 24 hours of insulin production and is often more accurate than fasting insulin. Could they need more time? 1 mos is not long enough for some. Also, what about sugar addiction and eating disorders- these patients are not always forthcoming due to fear of shame. How old and what sex? Postmenopausal women who have dieted repeatedly and are now in a state of metabolic dysfunction require much less carbs and a much longer period to respond positively. Check a uric acid in all of these women - it is often elevated and can be tracked for progress in addition to the other biomarkers. What about stress, PTSD? - fixing diet, doesn’t fix these. Stress can sometimes be seen on CGM but not always, sometimes the BS elevation is just a little above baseline, and a constant state of fight or flight causes cortisol release and higher BS which defeat ketosis. Certain medications can do the same thing. And finally, consider gut heath/microbiome issues and circadian rhythm disturbances. Hope this helps!!!
  January 6, 2024

• Nice comment. Individualizing care with finesse is very rewarding
  January 6, 2024

• Glad to support the stand against biased information, organisations and guidelines. We are stronger together.
  November 18, 2023