Troubleshooting after 4.5 years LCHF. Help?

[gabe]

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:

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

I’ve done this before but good idea.

Carb creep is real

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.

That ALT number is interesting for one.

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.

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?

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.

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?

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.

Have you tried:

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

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.

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

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

How’s your stress?

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.

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

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.

What about the almond flour and artificial sweeteners?

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…

Maybe check out Saladino’s recent notes about PUFAs leading to weight gain?

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!

lso one more thought: time outside makes a big difference for circadian rhythm, which influences all of our hormonal pathways. (

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.

good luck, Gabe!

Thank you Madeleine!

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.

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!

[Carnivoor]

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]

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.

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

[Carnivoor]

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]

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.

[FrankoBear]

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.

the importance of combining a regular intermittent fasting regimen with a low carb keto approach for longer term progress.

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

I’ve tried intermittent fasting

How is that at the moment?

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

14 Reasons Why You Might be Gaining Weight on Keto | Keto Lifehacker

[FrankoBear]

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]

Your hdl and triglycerides look quite fine to me. Maybe your weight gain is just a few too many calories.

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.

Would you go carnivore for a month?

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!

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.

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?

[FrankoBear]

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?

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?

[VirginiaEdie]

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.

[Madeleine]

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!

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.)

[ctviggen]

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:

Disastrous Trends in American Bacon - Fire In A Bottle

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).

[gabe]

Bumping

[Janie]

If you think your metabolism has slowed down…

Paging @lfod14 who experienced this and has suggestions to raise it back up

[lfod14]

I gotta agree with @Janie seems your metabolism has slowed. Reading up through everything it pretty much seems close to what happened to me. Every time you stall you tweak something that seems to be removal of something else, involvement of fasting etc and temporary fixes that then lead to more stalls. I’d definitely start tracking again, and taking a look at what you’re eating, I’m sure you still remember enough from tracking before to probably be able to catch a slow down from that alone, but I wound up just going in and getting my RMR tested, it was pretty bad by the time I did it.

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 used to smh at this one, as I’m sure you did at some point but there DOES seem to be some truth to this for some if us. I didn’t try to prove/disprove it directly, but after reading a bunch of other peoples results mainly on weight lifting forums that have gone LCHF and Keto they all said it happned to them after a while. These days I’m not doing strict keto anymore and have more carbs in there but definately still LCHF vs a “normal” SAD eater.

What fixed my 1700RMR was reverse dieting. I’d add 100 cals to my daily allowance every week until I started to gain, hold there until I didn’t, then keep moving up. If I gained 2 weeks in a row I’d drop 50 and go from there. I also slowly started adding carbs around workouts again. A lot of what I used to think was crazy about carbs helping metabolism seems to then be true for me, while before when I was heavier that stuff was a death sentence for me.

I’ve got ZERO science to back it up but my own theory is that our metabolisms are more like muscles than we think. We know CICO is far from perfect but I think there’s a real difference between eating 3000 cals, and burning back down to 2300, than just eating 2300 to begin with. I think all that work helps it get stronger. It seems my weight loss over time has been better when doing that. I think it also helps when we get a little stupid as far as mitigating the damage. Another thing I’ve gained with all this is a lot of metabolic flexibility. I’ve been averaging probably 150g carbs most days for months and last Saturday dropped the carbs back out until yesterday. Basically strict keto for 6 days while maintaining high protein, essentially a PSMF. No keto flu type stuff at all, just keep on running felt great, although a little bored with my menu since I kept the fat on the low-ish side. But my metabolism isn’t recognizable as the same one I had a couple years ago. We definitely change that way. If you have the ability, I’d definitely get your RMR checked, only takes like 20min.

[gabe]

Update: I may have cracked it. More details to come in a couple of weeks when I know more.

[Hallie]

Just read your whole thread Gabe and now I’m left hanging!
Happy to hear that you’ve worked something out though

[ctviggen]

If you have the ability, I’d definitely get your RMR checked, only takes like 20min.

Where do you get this checked? And what would having one “number” do for you?

For instance, I’ve gotten one testosterone test and one c-peptide test. Both were in the “normal” range. I have yet to figure out what to do with this information.

Read this for instance:

Sterculia Oil: Metabolic Results Number One - Fire In A Bottle

He has a $7,500 metabolic tester. He takes the test a few times daily, and each day, the results vary wildly. The lowest “resting” rate is 272 and the highest is 416. Now, he’s trying to show that his oil improves this, and also his “feasting” raises this, but still, there’s a huge variability.

[lfod14]

Where do you get this checked? And what would having one “number” do for you?

You can either have your Doc order it, put that’s kinda a PITA since they want to know “why” or just go to a place that has the equipment. My first one I had done at a place that trains cyclists, the second one I had done at a high end gym where the training department had them for measuring Vo2Max. What it does for you it tells you almost exactly what your metabolic rate is so you can work macros according, or just know that you’ve either sped up, or slowed your metabolism. In my case I was originally eating WAY more than my metabolic rate would allow and not loosing fat no matter what I did, or so I though. After my original test I had to drop my cals by almost 1000 just to get the needle moving again which worked almost immediately.

The second test I recently did confirmed that my reverse dieting was successful and confirmed that my once 1700 RMR is now in the 3400’s.

For instance, I’ve gotten one testosterone test and one c-peptide test. Both were in the “normal” range. I have yet to figure out what to do with this information.

As somebody that’s been on testosterone for years, being in normal range means nothing, as the range is constantly being lowered and doesn’t really mean much. From being all across the map on that one I don’t like coming down under 1000ng/dl. I have a good doc that likes me in the 900-1100 range which works out perfect, but much under that and I’m not right. When you see those Low T commercials telling you how you’ll feel 20 again, have tons of energy, be in a great mood, all that… There’s actually a lot of truth there, but you gotta get those numbers up to get that out of it.

[gabe]

Update: How I broke my 3.5 year stall