Troubleshooting after 4.5 years LCHF. Help?


(Gabe “No Dogma, Only Science Please!” ) #1

Things started well in 2016 when, in my first 10 weeks, I exercised a lot, ate relatively low carb (but still, heretically, ate some fruit) and lost 10kg. I maintained below about 82kg for nearly a year. This chart illustrates some portion of that lovely decline back in 2016:

A couple of years ago, I noted substantial weight gain that may or may not have been precipitated by a few days of steroids for sudden hearing loss (I’m ok now, it resolved itself and the steroids weren’t necessary to fix it.) That was sometime in December of 2017, and as you can see in my rolling 30-day average weight chart below – which I measure nearly every morning – there was a weight gain since then which never reversed itself.

I’m not happy with the trajectory; I’m now averaging 84+ kg, and my starting weight before all of this was 93.5kg. So despite avoiding carbs, and with little in my dietary habits fundamentally changing, I’m at a weight that’s now uncomfortable for me.

My bloods are all good, except, weirdly, the latest glucose result which is 5.4 here in Australia. I never had anything higher than 90 while living in the US. Could be an anomaly. I checked loads of bloods back in the US, including ApoE and advanced lipid profiles amongst many others. Happy to include them if anyone would like:

Anyway, I’m at a bit of a loss as to what I can do. I’ve tried intermittent fasting, single set to failure training, loads of cardio, no cardio, and various levels of stringencies on low carb. I’ve cut out alcohol except for 1 night per week (which for the eagle-eyed among you explains the improvement in ALT between July and September) and in the past I had extended periods with only black coffee, fearing that half and half milk or even cream was preventing my body from losing fat.

The bottom line is, I suspect I’ve heard every suggestion given to every newbie and every veteran, and I’ve tried probably all of them. One thing that has changed but doesn’t really explain the results is that I’ve been somewhat more sedentary this year as a covid refugee in Australia; back in NYC I walked a lot more. But it’s not correlative.

My diet recently has been 2 high fat cappuccinos (usually made with cream) by mid-afternoon. Then perhaps 3 eggs and some cheese. Very occasionally this might include hollandaise and salmon and avocado. The big meal is usually animal protein with a vegetable like cauliflower+broccoli rice, eggplant, broccolini, or similar. Dessert might be an allulose almond flour slice of cake, or some “well naturally” chocolate sweetened with stevia/erythritol. Or no dessert at all.

I wonder if anyone has successfully dealt with a similar long-term stall/gain. Is this just my Phinney weight? I’ve had my T checked and in the past Free T was low, but now all seems normal. My vitamin D is great. Perhaps this is where my body wants to be, given my level of insulin resistance? And I’m definitely insulin resistant, an OGTT in 2017 showed as much.

I should note that my doctor is low carb friendly, and he basically shrugged. He’s not worried about my numbers nor my weight. My rheumatologist, on the other hand, would like me to lose weight to take the strain off my poor knees. He might send me to an endocrinologist but I’ve seen one before and I don’t think there’s much they can do.

Would appreciate all constructive criticism. I’ve gone pretty deep with bloodwork and research in the past, and happy to consider anything I may not have thought of.

Tagging @richard because I wonder if you have seen similar cases in your extensive keto journey?


(bulkbiker) #2

1 Week of a very detailed food diary counting everything, weighing before cooking etc etc to check exactly what you are eating?


#3

It’s a good report Gabe.

Doctor’s lack of concern is warranted.

You seem to have the hang of it.

Carb creep is real so checking that as @MarkGossage says is a good exercise.

There is a lot to talk about. I can feel others thinking. That ALT number is interesting for one. But the fasting insulin, I think is key.

The reduction in physical activity this year will mean that your glycogen stores are less likely to empty in a 24 hour cycle. Have you been doing more resistance training during COVID. It’s the standard enquiry about what actually makes up your body weight? Have you more lean body mass since the initial weight loss?

An early thought on what I can see/read relates to some recent podcast episodes. I think it was Peak Human, it may have been Low Carb MDs, where they strongly reiterated the importance of combining a regular intermittent fasting regimen with a low carb keto approach for longer term progress.


(Bob M) #4

I don’t think 5.4 is that high for morning glucose, considering your body is glucose-sparing in the morning. What is your blood sugar in the evening?

I personally don’t think your insulin is that high, though you will see “if you get a fasting insulin above X, you’re insulin resistant”, where X is 4 or something really low. My fasting insulin values are all over the map (from 3.8 to 33 - no that’s not a mistake – all while low carb/keto). Usually around 10 though. And that’s after almost 7 years of low carb.

Got the lowest values consistently when I was fasting a ton. I find fasting harder now, though.

Have you tried:

  1. reducing/eliminating dairy?
  2. reducing fat, increasing protein?
  3. reducing/eliminating nuts, nut butters, nut flours?

When you got the OGTT, what were the results? Did you “carb up” before that?


(Edith) #5

How’s your stress?

You see a rheumatologist? Are there any meds you are on that could be causing weight gain?

What about the almond flour and artificial sweeteners?

I was just talking to my husband about almond flour last night. Think about how many almonds are ground to make 1/2 cup of almond flour. I think that eating the amount of nuts we get from eating a nut flour may actually cause us to eat an unnatural amount of nuts at one time. I ate an insane amount of almonds when I was making keto breads and desserts. I believe they caused me problems over time.


#6

Maybe check out Saladino’s recent notes about PUFAs leading to weight gain? I actually don’t see much in the way of those fats in your eating except almond flour but not sure if you’re eating a lot of chicken or pork.
Also - I’m sure you’ve tried this because people mention it all the time - but many folks find that they gain weight with dairy no matter what else is going on.


#7

Also one more thought: time outside makes a big difference for circadian rhythm, which influences all of our hormonal pathways. (I’m not sure how that would connect to time in NYC, since you often don’t get direct sun in midtown Manhattan except for summer…)
good luck, Gabe!


(A fool and his bacon are soon parted) #8

Paul Mason says that the best indicators of whether there is insulin-resistance or not are the HOMA-IR score or the combination of HbA1C and C-peptide. Of course, there’s always an oral glucose tolerance test, but nobody likes taking them or doing them. But Dr. Kraft worked out the predictive value of the response patterns a couple of decades ago, and they convinced him that there are a lot of as-yet undiagnosed diabetics running around.


(Gabe “No Dogma, Only Science Please!” ) #9

Thanks all for the ideas, here are some responses. I feel like if I can troubleshoot my issues, it might actually be really helpful to others who are experiencing similar long-term LCHF issues:

I’ve done this before but good idea.

True, though I am quite certain I’m as low carb as I was before. Nevertheless, a food diary isn’t a bad idea.

Frankly one hypothesis I have is that my metabolic rate has dropped as a result of eating low carb for so many years. No evidence to back it up though.

I’m concerned about both ALT and AST. Even when they’ve both been in the early 20s, they’re a worry. Peter Attia likes his patients to have them in the low teens.

No, I’ve become more and more sedentary during covid and if anything lost LBM. Though I think I will need to add exercise (especially strength training), I don’t see a correlation between the weight gain and exercise. I was getting loads of steps in every day in NYC, and doing single set to failure strength training, and was trapped in the 82.5-83.5kg range for a long time.

The thing is, when I was wearing a Freestyle Libre, I didn’t have high BG in the morning. CGMs aren’t very accurate in my experience, but I felt like generally my BG was optimal (80-90 in US terms) and stable.

Yes, kind of, and yes. Right now, I drink mostly cream cappuccinos, eat cheese, eat peanut butter, have almond flour stuff occasionally, and haven’t consciously dropped oils/butter. Could totally try all of this for a few weeks.

Yep, I actually went back and looked at the notes I took in my weight-tracking spreadsheet, and I wrote that I was having high carb prior to the OGTT. The results are in this post: https://www.ketogenicforums.com/t/help-me-interpret-my-glucose-tolerance-test/21061?u=gabe

Not massively different than usual. If anything less, on balance, than at my last job. So I don’t think it’s correlative with my weight gain/stall.

Rheumatologist said today that he’s determined that I don’t need him and he referred me to a sports doctor and an endocrinologist to help me resolve the mechanical joint issues + the weight issue. In fact he thinks I shouldn’t waste time with the latter and see if the sports doctors can help me solve the problem with training.

No meds.

When I cook, I use allulose, but it’s very expensive here in Australia. The chocolate I currently eat is made of stevia and erythritol. That could be a factor. Though I’ve gone zero sweetener before, and it hasn’t moved the needle…

I am super careful nowadays to avoid vegetable oils of any kind. I eat primarily butter and olive oil, with some coconut oil. The only veg oils I’d consume would be in delivery food, and I’ve been eating at home almost exclusively since March!

I’m back in Australia. While I’ve been much more sedentary, I spent all of winter in the sun and I’ve been getting out now in the spring – because we’ve almost eliminated the virus here, I now feel comfortable sitting at cafes etc.

Thank you Madeleine!

Thanks @PaulL, see above re OGTT. Paul Mason actually looked at my results at Ketofest in Canberra a couple of years ago and said, “yep, you’re insulin resistant.” I go a bit hypoglycemic after a 75g glucose load. My GP had said as much when I had the test in 2017. It’s not enough for them to insist on Metformin, but to give some context, the same GP who gave me the OGTT in 2017 recently prescribed me extended release Metformin at my request. I haven’t started taking it though because my sudden hearing loss in late 2017 came shortly after I took Metformin the first time – that latter half of 2017 was the first time I really started trying to troubleshoot the stubborn weight loss stall.

Anyway… I suspect there are no simple answers to any of this. I may have to do some trial and error with some of the suggestions people have made above. It may well be that my Phinney weight is just higher than I’d like, though from a mechanical perspective this wouldn’t be great in the very long term because of my joint (specifically knee) issues!


(Vic) #10

Dear Gabe,

I was comparing your bloodwork to mine and notest something in the reference.

For ALT: if I plug in your value in my lab reference range your values are normal range. Normal for male is <50U/L and normal for female <40U/L. So, unless you are female those ALT values should be black, not red.
On older bloodwork of mine, pre 2017, the normal range for ALT was 21-72 U/L

Albumin is not in my bloodwork. found some reference ranges online, normal range 35 to 55 g/L. Again the numbers should be black, not red.

So the question is. Is there something wrong with your numbers of with the labs reference.

brgds
Vic


(Gabe “No Dogma, Only Science Please!” ) #11

Right but the standard range includes the SAD population of chronically diabetic sugar burners who have NAFLD! I’d rather my values be under 20. Hoping my liver continues to recover.

Note that the high ALT value from mid this year was almost certainly due to high daily alcohol consumption which I then cut to weekly, bringing the ALT down to a semi-decent level


(Vic) #12

Fyi
Early keto my number was 34. 2017
on carnivore. Last year it was 21. 2019
I’m due for my anual bloodwork.


(Ippy Bear) #13

I think your glucose seems fine to me. I’ve just had mine checked and it’s the same of yours ( keto for me, nearly 3 years now ). I have done some research and it’s seems quite a few keto people have the same higher morning glucose levels. In all the cases I have seen though, and mine included, those levels get lower through the days, not being particularly affected even after a large meal. ( I did a test the other day eating a 100g bar of chocolate that’s been in storage for a long time and after that my glucose level rose to 6.4 / 116us, a relative non event, sat there an hour then dropped ). Your hdl and triglycerides look quite fine to me. Maybe your weight gain is just a few too many calories.


#14

Hey Gabe

I am enjoying the thread. Like you say troubleshooting threads can help many as they reflect it back on themselves.

Agreeing with @ctviggen Bob here. One thing I see is a variety of foods. Some people champion that. But a variety of foods could also be a variety of confounding low grade food reactivities: dairy products, peanuts, sweeteners, other tree nuts. Would you go carnivore for a month? Anecdotally it shifts weight plateaus on a regular basis. But I don’t know your thoughts on it as an elimination diet.

Takes us back to eating and not eating timing. You mention IF in the paste tense.

How is that at the moment?

This blog article has a nice check list of what a few inputs have been mentioning.


#15

On ALT.

Interesting what you say about Peter Attia and optimising that result.

Elevated or high normal range does point at potential liver cell injury. Definitely alcohol will affect the level. And alcohol will affect other aspects of low carb eating as it is a priority to detoxify or excrete ahead of glucose.

How would you go dropping it all together?

I’m long term keto, like you and noticed at the 4.5 year mark that I had developed a magnesium deficiency that had some clinical signs of muscle cramping, and eventually heart arrhythmia. Makes me wonder if consistent nutritional ketosis could be associated as a chronic draw down disease (like veganism). The indication that magnesium deficiency was a place to look was repeated elevated ALT results. I fixed it with supplementation.


(Gabe “No Dogma, Only Science Please!” ) #16

Thanks, yeah the lipids are fine, but a fasting BG of 5.4 is very unusual for me. That 99mg/dL, I generally have tested in the 80s for years. I actually had a blood draw today, should have insisted on a fasting BG test.

Anyway the reason I posted some of the more recent bloodwork is to illustrate that in general these numbers are pretty good and consistent with a low carb approach.

Probably not, although I don’t think it would be especially unhealthy. I’ve gotten my body adjust to quite low levels of carb, I think going to zero carb is very experimental right now, bordering on cultish. But to each their own.

Re IF: For much of this year at least, I don’t get hungry till mid- to late-afternoon usually. But I love my coffee. And for most of this year, I’d make myself two cappuccinos with heavy cream in the very late morning/early afternoon, and then have nothing till much later in the day – even though I felt zero hunger and completely satiated by the time I got to the coffee. I often felt like I was almost forcing myself to drink it because of my level of satiation. I just love coffee; and black coffee doesn’t cut it (I’ve tried for weeks/months at a time, and even during the pandemic for a while!)

I have occasionally wondered what would happen if I simply didn’t consume a single calorie till I got peckish (which would mean no coffee for me for the foreseeable future.) If I did this, and if I restricted myself to not eating after say 9pm, I’d be IFing pretty stringently, though I also think that if I stopped eating earlier in the night then I’d get hungrier earlier in the day. I wonder if the eating window itself might be a part of the answer.

Frankly I have been disturbed by just how satiated my diet makes me. I know this is supposed to be a good thing, but combined with the weight gain and with no discernible change in my eating habits, it’s very worrying.

My family have noted how little I seem to eat, and have expressed concern at how stringent my “diet” seems to be. I’ve told them I’m actually very happy with low carb eating, and I don’t really miss anything in SAD, but the fact that my family thinks of me as ascetic suggests to me that my own sense that I’m eating rather strictly LCHF is not just subjective. I could keep a food diary, but I doubt it would tell us a great deal about what’s going on here. Maybe it would though.

None of the more obvious “reasons” why people might gain weight on keto stand out to me, though again I’m prepared to go back to basics, cut things out again, etc etc. It’s very frustrating to be honest; that first few months of low carb was easy, I was still eating mangoes and dropping weight fast. Now I can’t even dream of eating fruit without gaining weight!

This is interesting. I just checked a moment ago and my Mg has been fine – I was also supplementing at one point, and perhaps I will again. What do you mean by draw down disease? You mean that vegans tend to have reduced levels of certain vitamins and minerals in the long term? What other long-term issues do you see with following keto/LCHF?


#17

Draw down disease is as you surmise. That your body stores nutrients and energy in various tissues. But in the context of a specific nutrient deficient diet, or increased losses for some reason (e.g. nutritional ketosis and diuresis) that eventually depletion of stores occurs that then lead to measurable deficiency. Vegans get it with some vitamins and some essential amino acids.

The micronutrient deficiency was the only long term effect that was noticeable and diagnosable in my n=1. I was doing things like adding medium chain triglycerides to my coffee and their may be some genetic predisposition in my northern European heritage linking that to some of the symptoms or exacerbation of the root cause.

If you like coffee, why have it with dairy? I know you tried black coffee and it was not to your taste. But that is coffee (and water)…

Years ago in keto weight plateau discussions a common first step for solving the issue was to cut dairy from the eating (and drinking plan). That approach is a dysfunctional approach to an elimination diet plan. But if it is the cause, some people can get lucky.

An elimination diet may be a way for a thinker and experimenter like yourself to identify issues with the current way of eating (and lifestyle) that is not working. That’s where zero carb, and dare I say it, zero carb without coffee comes in for a set period of time (usually about 42 days) before testing reintroductions. Note: I tried it in October just past and lasted 3 days before coffee was reintroduced and I realised I am addicted to it.

The other thing in that blog list is sleep. How many hours of sleep are you getting, especially with 2 coffees that reach into the afternoon?


(Edith) #18

How long did you try going dairy free? Maybe you didn’t give the trial enough time? You do eat a lot of dairy between the heavy cream, cheese, and hollandaise sauce.

Also, the allulose could be a problem. When I was making keto treats, I tried using allulose. It made my husband’s heart race.

A thought might be to try the Atkin’s induction phase: just meat and leafy greens if you don’t want to go all the way carnivore.


#19

Sorry to give such a brief response to such a thorough reply from you but just in case it’s useful: some of the biggest sources of PUFAs for those of us in this WOE are poultry, pork and nuts. (E.g. from what I gather, pigs store PUFAs directly in their fat, so unless the pigs we eat are on a low PUFA diet, then we get all of their vegetable oil intake when we eat their fat.)


(Bob M) #20

Ruminants (eg, cows, lamb/sheep, etc.) have bacteria that change PUFAs to saturated fats. This is why even grain-fed (though exactly what is meant by this term is open to much fighting) cows have low PUFAs.

Chickens and pigs, on the other hand, are what they eat. See this for instance:

As for dairy, I’ve tried not eating dairy and eating dairy. For the amount of dairy I typically eat (1 tsp or so in my coffee, unless I’m fasting), then maybe some cheese sometimes and maybe ricotta sometimes, it doesn’t seem to make a difference. Or if there’s a difference, it’s hard to find.

On the other hand, my wife has quit most dairy and seems to have improved certain aspects of what she thinks is important.

Note too that the type of dairy makes things confusing (look into A1/A2 proteins). I generally eat higher fat stuff and A2 protein or denatured proteins (long-fermented, hard cheeses).

Thus, I avoid too many discussions of “dairy” unless someone is more specific.

As for nuts, I do eat these sometimes. My wife made some chicken skewers and made peanut sauce. It was great. But I don’t have nuts too often.

As for fat, that’s also fraught with opinions. My opinion: I like higher protein, lower fat better; I really don’t like suet, I mean it’s OK, but doesn’t seem to do much to me and doesn’t seem to be as satisfying as just eating meat; higher saturated fat is probably better than MUFAs and probably a lot better then PUFAs. I’m more of a Ted Naiman (high protein) than Jimmy Moore (high fat).