As I said, you need to really crank up the fat intake to push yourself over the adaptation divide as quickly as possible. If you don't like fatty cuts of meat, you can add a little medium-chain triglycerides (MCT) to your diet. MCT are absorbed more like carbohydrates and are used quickly by the body. They are almost never incorporated into the fat cells, so they burn quickly, and any extra that might be hanging around are converted to ketones. So, MCT will drive the ketone production process. And so will coconut oil if you prefer that.
You can find MCT oil at most health food or natural grocery stores. It has never bothered me, but some people can get a little nauseated if they take too much of it, so if you decide to give it a try, start out slowly. Or go with the coconut oil.
Aside from the occasional carb cravings, which we'll deal with later, the most common symptoms experienced by those getting started on low-carb diets are fatigue, headaches, light-headedness or dizziness, and cramping. I would say these four symptoms probably comprise 98 percent of the complaints we get from our patients we put on low-carb diets. Not everyone experiences these symptoms - especially those who do what we tell them - but of those who do have symptoms, these are almost always the ones they have. Let's look at what to do to avoid them or treat them should you already be experiencing on or more.
Electrolytes
The most common cause of virtually all the symptoms listed above is an imbalance in electrolytes. Following a low-carb diet results in a rapid lowering of insulin levels, which - though a good thing - can create problems in the early days. We'll address the electrolytes in the order of importance.
Sodium
When you are overweight and insulin resistant, you have a lot of insulin circulating in your blood most of the time. This excess insulin does a number of bad things to you. Gary Taubes wrote an entire book about how excess insulin makes you store fat in your fat cells. But the story doesn't end there. Excess insulin also drives the kidneys to retain fluid, which is why many obese people retain a lot of extraneous fluid and experience pitting edema in their lower legs.
What is pitting edema?
If you push your finger into the tissue in the front (or just to the side of) your shin bone and your finger leaves an indentation - almost a finger print - that takes a while to fill back in, you have pitting edema. Most overweight people experience this phenomenon late in the afternoon and/or at night after being on their feet all day. The excess fluid pools around the lower legs and seeps into the soft tissues. In the morning, after the body has been horizontal through the night, the fluid redistributes, and the pitting edema goes away but then reoccurs as the day goes on. Even people who aren't all that overweight but who do have elevated insulin levels will have some degree of excess fluid accumulation even if they don't experience pitting edema as evidence of it.
One of the first things that happens when people go on low-carb diets is a rapid improvement in insulin sensitivity. Because the low-carb diet starts to quickly banish the insulin resistance, insulin levels fall quickly. And as insulin falls, the stimulus to the kidneys to retain fluids goes away, and the kidneys begin to rapidly release fluid. One of the common experiences at the start of low-carb dieting is the incessant running back and forth to the bathroom to urinate this excess fluid away. Which is both good news and bad news.
The good news is that it's great to get rid of the excess fluid but it comes at a cost, which is the bad news. As the excess fluid goes, it takes with it sodium an extremely important electrolyte. When sodium levels fall below a critical threshold (which can happen within a short time), symptoms often occur, the most common being fatigue, headache, cramps and postural hypotension.
Postural hypotension happens when you stand up too quickly and feel faint. Or even pass out briefly. It's a sign of dehydration. So if you've started your low-carb diet, made your multiple runs to the bathroom, and jump up off the couch to answer the phone and feel like your going to faint (or actually do pass out momentarily) and have to sit back down quickly, you've got postural hypotension. It's really easy to fix - you simply need to take more sodium and drink more water. Salt your food more. Increasing sodium is just another one of the many counter-intuitive things about low-carb dieting. Just like eating more fat to lower your cholesterol. You've got to start thinking differently. The low-carb diet is one that absolutely requires more sodium. A lot more sodium.
If you've got the brutal headaches that some people get when starting on a low-carb diet, add sodium. And drink extra water.
Even if you don't have pitting edema, postural hypotension or headaches, you still need more sodium if you are starting out on or following a low-carb diet. It's critically important that you get extra sodium. I can't make this case too strongly.
An easy way to get extra sodium along with magnesium and potassium (a couple of other electrolytes we'll discuss in a bit) is by consuming bone broth. Unfortunately, you typically have to make the good stuff yourself because it's difficult to find commercially. You can get chicken broth and beef broth at most grocery stores, but it's not nearly as good as the broth you can make yourself. At the end of this post I'll give you a spectacular recipe that we have for a great bone broth we made at our now-defunct restaurant. It is beyond good. It requires a little time, but you can make a bunch and freeze it in small containers and keep it forever.
Short of making your own bone broth, you can use commercially available bouillon, which contains plenty of sodium and makes a nice hot drink. Plop a cube in a cup of hot water and throw it back. Many patients have reported that drinking a cup of hot bouillon helps them get through carb cravings. It's easy and convenient, but can't compare in taste to the real bone broth you make yourself.
Comment: The thing to watch for in bouillon supplied in most stores is that it invariably contains MSG, which you want to avoid at all costs.
In addition to broth, get some Celtic Sea Salt, Himalayan Salt or one of the other grayish, pinkish kind of grungy looking salts and replace your normal salt with these. And don't use them sparingly. These salts have been harvested either from ancient sea beds or obtained by evaporation of sea water with high mineral content and contain about 70 percent of the sodium of regular salt (which has been refined, bleached and processed until it is pretty much pure sodium chloride, often with anti-caking agents added). The other 30 percent of the volume is other minerals and micronutrients (including iodine) found in mineral-rich seas. Consuming these salts is not just following a Paleolithic diet using modern food, but, depending upon the origin of the salt, it is consuming the same food your Paleolithic ancestors ate. I much prefer these salts taste-wise to regular salt, and I salt the heck out of all my food with it.
Magnesium
The low-carb diet doesn't really cause a massive depletion of magnesium like it does with the sodium and potassium (the next electrolyte on the list), but most people who are overweight, insulin resistant and/or hypertensive or diabetic are deficient in magnesium. Even people with lipid problems are often magnesium deficient. In fact, even people who don't seem to have health problems can often be magnesium deficient because most people don't get enough. The last I read on the subject, about 70 percent of people don't even get the minimum recommended daily intake of magnesium (which isn't all that high). So, in my opinion, it's important to supplement this vital mineral. Good magnesium levels help regulate potassium as well, so keeping your magnesium adequate helps with your potassium as well.
Nature has designed us so that approximately 300 plus of our enzymes require magnesium as a co-factor to make them work properly. Which tells us that we evolved in a time when magnesium was readily available, otherwise the forces of natural selection wouldn't have made such wide use of it.
Where did it come from? I would bet most of it came from the water. Most natural sources of water have a high magnesium content, so when you drink bottled water and softened and treated water, you get short-changed. Magnesium salts in water are one of the substances that tends to make deposits on your water pipes and makes it difficult to get a good lather with soap. This problem is solved with water softeners, but the process gets rid of the magnesium. In the old days when we all drank well water or stream water, we got a lot more magnesium.
Since magnesium is used in 300+ different chemical reactions in the body, a shortage of magnesium can cause problems. One of the most common ones is an increase in cravings. Often simply replenishing magnesium gets rid of many of the food cravings people have.
The best way to get magnesium is from supplements. Get a good chelated magnesium supplement and take 300-400 mg per day. We've found it best to take these supplements in the evening because magnesium is relaxing and taking it in the evening helps you sleep. About the only problem people ever have with magnesium is loose stools, i.e., the milk of magnesium effect. If that happens - and it is unwelcome - simply reduce your dosage until your stools normalize.
Purchasing magnesium supplements can be a little tricky because of the way they're labeled. First, a chelated magnesium supplement is one that ends with an '-ate,' as in magnesium aspartate or magnesium citrate or magnesium citrimate. The -'ate' ending tells you the magnesium is chelated, which means it's attached to another molecule (the chelating agent..aspartate, citrate, or whatever) that helps with absorption. Second, with magnesium supplements, the manufacturers sometimes list the dosage of both the magnesium and the chelating agent combined. Since the chelating agents are a lot heavier than the magnesium, this labeling often ends up saying the dosage of each pill is, say, 1000 mg of magnesium aspartate. This isn't the amount of magnesium you're going to end up getting because the magnesium is only about 15 percent of the weight of the total pill.
About the only way you can really tell how much actual magnesium your getting is to look on the label on the back and see how much of the RDI (Recommended Daily Intake) the dose is. The RDI for magnesium is 400 mg per day so if you find the dose of the supplement you are considering contains 50 percent of the RDI, then you know each dose contains 200 mg of magnesium irrespective of what the dosage is on the front of the bottle. As I say, I recommend 300 to 400 mg of magnesium per day. The only downside of magnesium is loose stools. Doesn't happen to everyone, but does to a few. For many people the magnesium seems to offset the constipation that some experience when starting a low-carb diet. If you do experience loose stools, simply back off your dose of magnesium until things unloosen.
Magnesium is nature's relaxant. It makes many people sleepy, so we always recommend taking it at bedtime.
Potassium
Potassium is linked to sodium. If you lose a lot of sodium through the diuretic effect of the low-carb diet, you'll ultimately lose a lot of potassium as well. Keeping your sodium intake up as mentioned above will help preserve your potassium as well. And keeping your potassium levels up helps to ensure that you don't lose a lot of lean muscle mass during your weight loss. Plus, just as with sodium, adequate potassium prevents cramping and fatigue.
You can replace your potassium by taking potassium supplements. In our clinical practice, we gave all patients starting the low-carb diet a prescription for potassium. You can get the same dosage by taking four to five of the over-the-counter 99 mg potassium supplements you can purchase at any health food or natural grocery store.
There are a couple of prescription medicines that you've got to be aware of if you markedly increase your potassium intake, so if you're on blood pressure medicines, ask your doctor if it's okay for you to take potassium.
Before we move on to other supplements we can use to help with low-carb dieting, I want to address the subject of dehydration.
Hydration
A few years ago, I learned the lessons of adequate hydration the hard way, so take this as a cautionary tale and benefit from my painful experience. I had always pooh-poohed the notion of drinking a lot of water in addition to coffee, tea and other non-caloric beverages because I always figured (and probably have even written in the pages of this blog somewhere) that coffee, tea, etc. are nothing but water with a little flavoring in them. I mean, if you start out with a glass of water and put tea bag in it, the water doesn't go away. It's still there; it just becomes tea-flavored water. Well, turns out that's not actually the case.
My daily ritual was as follows: Get up, stagger to the refrigerator and take a big gulp or two of sparkling water. Then make my way to the espresso maker and crank out a cup of Americano. Followed by four or five more Americanos over the course of the morning and early afternoon, interspersed with a gulp here and there of sparkling water. A snort of Jameson in the early evening, maybe a glass of red wine with dinner and a decaf Americano after dinner. If I watch a movie or read a book, I usually nurse another glass of Jameson. I typically take my supplements at bedtime, so I throw back another half glass or so of sparkling water then. Plenty of liquids, right?
Well, not exactly, as it turned out.
I began developing severe cramps in my hands and feet that I had a hell of a time massaging out. That was just the beginning. I started being awakened at night with brutal leg cramps, requiring my springing from the bed and walking them out. My potassium is too low, thought I, so I started taking potassium. No change in the cramping situation. In fact, if anything, it got worse. I was complaining to a friend who told me calcium had helped his cramps. So I downed calcium at bedtime. No improvement.
Another friend told me that tonic water had helped her with cramps, but I only half believed it, so didn't really try. Then MD and I had family visit us in Tahoe for skiing. I upped my booze intake, kept the coffee intake about the same, and probably decreased my consumption of sparkling water (or water of any kind, for that matter). The cramps increased dramatically. And what was worse, they stopped limiting themselves to the night. When MD and I were driving over to Napa one day, the cramps were so severe I could hardly drive. I had to keep the seat back as far as I could get it so I could straighten my leg when one hit me. Then my hands started cramping just holding them on the steering wheel. I pulled off the freeway and made a beeline for a convenience store and grabbed a one liter bottle of diet tonic water and proceeded to chug the entire thing as I drove down the road. Miraculously, my cramps subsided. So, I figured tonic water (quinine) was the solution.
One night - after being out of tonic water for a few days and being failed by my bride in resupplying - I had another brutal night of cramps. The next day I was scheduled for blood donation. After going through the long list of questions that must be answered verbally (and fighting down the impulse to tell my interrogator that I had recently paid for sex while imprisoned in Africa - those who have given blood lately will know what I mean), I was sent to actually have the blood taken. The phlebotomist couldn't find my vein, which had never happened before because I usually have rope-like veins in my forearms. She asked if I was dehydrated. I told her I didn't think so since I had had my normal four of five cups of coffee that morning along with my gulp of water. She brought me a couple of 16 ounce bottles of water that I drank, and, bingo, there were my veins. Big and robust as usual.
It finally occurred to me that my cramping problem might be due to dehydration and that the diet tonic that solved the problem did so not because of the quinine but because I was drinking all the water the quinine was dissolved in. And it occurred to me that the cramping was worse in the middle of the night because a lot of water is lost through the breath at night. (See my second post on the Anthony Colpo Smackdown to read more about this.) You can lose a couple of pounds during sleep simply by breathing water vapor away, which was, I'm sure, what was happening to me. I was barely hydrated enough to prevent cramping while awake, but when I slept and my fluid level fell due to my breathing water away, I hit some critical threshold of fluid that kicked off the cramps.
I started rehydrating first thing in the morning and throughout the day. Now I get up, drink anywhere from 16 to 32 ounces of remineralized water (more about which later) first thing. Then I head to the espresso maker and start my daily Americano regimen. But I consume at least 8 ounces of sparkling water after each cup of coffee. And I drink water after each shot of Jameson and/or glass of wine (or any other alcoholic libation),* and I'm proud to report that I have been cramp free since upping the water.
My brush with cramping misery inspired me to hit the medical literature to read about hydration. And I learned many wonderful things. For example, I learned coffee is a diuretic (which I already knew but had chosen to forget), but that some acclimation occurs over time. Still, due to the diuretic effect, you don't get the full fluid from a cup of coffee that you would from an equal amount of water. Same with alcohol. Once I started calculating how much fluid of that I drank throughout the day I was actually retaining, I was amazed that cramping was the worst that happened to me.
I learned that water has a lipolytic effect (fat burning). I read this in a number of papers that had studied it, and the data clearly showed that those who took in a lot of water had increased lipolysis. I didn't deny the data, but I couldn't figure out the mechanism (and apparently neither could any of the authors because none described it). I thought on it a while and finally came up with what I think is a plausible scenario.
When you drink water, especially cold water, you require some increase in caloric burning to bring the water to body temperature, but that increase doesn't amount to all that much (the authors did describe this phenomenon), but you also dilute your blood for a bit until the water equilibrates with the fluid in all the tissues, and effect that takes some time. During this time, while the blood is more dilute, the concentration of the various substances carried in the blood decreases. Which would mean that insulin levels would fall. The typical blood volume is about 5 liters, so drinking a liter of water would increase the blood volume temporarily by about 20 percent, which would mean the concentration of insulin and other molecules in the blood would fall by about 20 percent. A 20 percent drop in insulin levels would allow fat to escape the fat cells and would facilitate its transfer into the mitochondria for burning. At least that's my explanation for the lipolytic effect seen in numerous studies of subjects increasing water intake.
Those starting a low-carb diet are prone to dehydration because excess ketones are gotten rid of via the kidneys along with a lot of fluid. So, when you start your diet, consciously increase your fluid intake. Do like I do now and come up with some sort of regimen that ensures you consume plenty of water throughout the day. You'll feel better; you'll avoid cramping; and you'll actually burn a little more fat. And don't make the mistake I did and assume that drinking a lot of coffee, tea, booze or other diuretic fluid is a replacement for water intake.
Since I drink either bottled water or water that comes through our RO filter, both of which are depleted of minerals, I always remineralize my water by adding a pinch of Celtic Sea Salt or one of the other such salts to each bottle. I add enough so that the water just barely hints of a salty taste.
Supplements
Every patient whom we started on a low-carb diet left our clinic with six supplements: lipoic acid, CoQ10, Vitamin E, magnesium, a good multi-vitamin and a prescription for potassium. (Now I would add a substantial dose of vitamin D3 to the list, a dose based on vitamin d levels and sun exposure.) We've already dealt with the potassium and magnesium, so let's consider the others.
First, the good multi. I'm a believer in getting most of what's needed vitamin- and mineral-wise from food. And I'm also a believer that I'm an excellent driver. Yet I always purchase car insurance. I see a good multi-vitamin as the same thing - cheap insurance against any kind of deficiency. I would rather have my patients urinating away fifty cents worth of vitamins a day than risk that they have a deficiency in one. And I feel the same way about myself. So, find a good multi-vitamin without iron and take it. Based on the experiences of my own patients, I can almost guarantee you'll feel better. Why without iron? Because most people on low-carb diets get plenty of iron in a very absorbable form. And too much iron isn't a good thing, so don't take it in your multi.
Alpha lipoic acid (ALA)
ALA is, next to magnesium, just about my favorite supplement. It acts as both a fat-soluble and water-soluble anti-oxidant so it can pretty much weasel its way in anywhere in the body and stamp out inflammation. It protects fatty membranes and even acts as a cellular nutrient. It also helps the body deal with blood sugar, which helps the whole low-carb adaptation process along. Many studies have shown an improvement in blood glucose levels and insulin sensitivity with ALA supplementation. ALA can rejuvenate other anti-oxidants, and has so many virtues that entire books have been written about it. My standard dose is 300 mg per day for patients starting low-carb diets. There is a newer, more potent version of ALA available now called r-alpha lipoic acid. The standard stuff is a combination of the r and l varieties, and since the r isomer is the active one, a supplement made entirely of the r variety is going to be more potent. And more expensive. If you use the r-ALA you can take 100 mg a day.
CoQ10
Another superstar supplement, especially for those who have been on or are on statins. Statin drugs interfere with the body's synthesis of this important nutrient, and those who have been or are taking statins are usually depleted to some degree. If you've been taking a statin, I would take 300 mg per day of CoQ10. If you haven't, 100 mg per day should do.
Vitamin D3
I would also add at least 1000 IU per day of this nutrient. You need to have your levels checked at some point to make sure you don't overdo it, but at 1000 IU per day, this is unlikely. If you do test and find you're deficient, I would take 5,000-10,000 IU per day until 25 (OH) vit D serum levels are up to at least 50 ng/ml. Along with all the other benefits vitamin D3 provides (which I have written about elsewhere on this blog), there is some evidence that it even boosts weight loss a bit.
5-hydroxytryptophan
The last supplement I'll mention is one I've had much success with in treating people who tend to have carb cravings late in the day. 5-hydroxytryptophan (5-HTP) is the precursor to serotonin. Most people who have carb cravings have them because their serotonin levels fall. Taking 5-HTP will bring them back up. It also helps with sleep. Best time to take it seems to be about 4 or 5 PM for those who go to bed at the standard 10-12 PM. You can move the dose around to find a time that helps the most with your carb cravings yet doesn't make you sleepy other than when you want to be. I usually recommend 50-100 mg. It's available at most health food stores and natural food grocers.
Fatty liver
The last bit of advice I'll give is that you need to work to defat your liver as quickly as possible. The good news is that you can do it quickly on a low-carb diet. Studies have shown major improvement in just 10 days or so. It's important to defat your liver to help you lose weight more quickly because the liver breaks down insulin. If your blood sugar goes up, the pancreas makes and secretes insulin to drive it down. It does so by driving the glucose into the cells. At the same time, insulin drives fat into the fat cells and keeps it there. As long as the insulin is in the circulation, it's going to be preventing fat from leaving the fat cells. The liver is the organ that breaks down and gets rid of the insulin. And a healthy liver does it a lot better than a liver full of fat.
One of the liver's most important jobs is detoxification of harmful substances. We all (at least I) consume medications, food and drink that is toxic. We (I) drink coffee, tea and alcoholic beverages. The caffeine and alcohol are toxins. They don't really hurt us in the quantities that most of us ingest, but they are toxic nevertheless. The liver detoxifies them. Same with many drugs - both prescription and over-the-counter. Tylenol puts a major detoxification burden on the liver. When you drink coffee, tea, and/or alcohol and take OTC meds, you occupy much of your liver's detoxification capacity. Which means it can't get rid of insulin as well and can't regulate metabolism in general as well as it does when it isn't busily detoxing toxins.
So, if you really want to hit it hard in the early phases of your low-carb diet and reach low-carb adaptation at warp speed, I would recommend avoiding - or at least limiting - coffee, tea, alcohol and OTC meds.
I am a huge lover of coffee and alcohol (coffee more so than alcohol despite my constant talk of Jameson) so I know this is a sacrifice. One way to have it both ways is to switch from caffeinated coffee to decaf espresso. Decaf coffee to me sucks taste-wise. But decaf espresso ain't so bad. If you don't want to go completely cold turkey, you can switch from coffee to espresso since espresso has double (or triple) the taste of coffee yet only about half the caffeine. My favorite way to drink espresso is as Cafe Americano. I love it so much that I even made a video of how to make it to send to people. Take a look if you haven't seen it yet. It's the best cup of coffee you'll ever have. (I have one on the table next to me as I write these words on the patio in Cuenca, Spain.)
That's about a wrap on my tips and tricks for kicking off a low-carb diet. I'm sure many of you have tips and tricks of your own. Please feel free to share them in the comments section.
The bone broth recipe at the very bottom of this post is from our defunct restaurant that I wrote about here. We had this going on the stove all the time and used it as a base for about half the dishes we served. It is absolutely spectacular. I would eat is as a soup (we didn't serve it that way) and take home bags of it and freeze it. You can do the same. I'll provide the restaurant-sized version so you can either make a large amount in a big stock pot and freeze a bunch of it in individual packages. Or you can cut it down to a smaller recipe. If you do, just make sure to cut all the ingredient amounts proportionally.
A note of interest: I wrote the first part of this post flying between San Francisco and Dallas. The middle part during a flight from Dallas to Atlanta. And the last part (along with the words I'm typing now) over the Atlantic on a flight from Atlanta to Madrid. I'll transfer it to WordPress, put in all the links and photos when I get to the hotel in Madrid. So you'll end up with a post that was written about halfway around the world.
Another note of interest: I'm finishing this post in Cuenca, Spain (including some of the edits I made above) because the internet connection in our hotel in Madrid sucked. The hotel was great, the food was pretty good, but the internet was abysmal. I kept getting kicked off, so I abandoned all but the most necessary internet functions (email, mainly) until I got to more reliable service. Here we are in Cuenca where the hotel sucks, the food really sucks but the internet connection is great.
One housekeeping note: Since the internet has been so unreliable, I have been unable to deal with the 100 or so comments that have accumulated. I'll get to them as soon as this post is up. I did perform one of my most-hated tasks last night and went through the spam filter to fish out legit comments that had gotten snared before deleting the zillions of spam comments. So if you've been waiting a long time for a comment to appear, it was probably one of the handful that I rescued from the sea of spam. I'll get it up as soon as I can. Just bear in mind that I'm headed for my next stop, Zaragoza, as soon as I hit the 'Publish' button on this post and will be on a forced march for a bit. So, be patient with me on the comments.
This is the restaurant recipe for massive quantities, so you can reduce accordingly. Just make sure you reduce all ingredients proportionally.
2 oz roasted garlic (weight)
10 oz roasted red onions (weight)
4.5 gallons water (volume)
22 oz tomato paste (weight)
4 oz cilantro with stems
2 pounds chicken back bones (weight)
16 oz tomato pulp (weight)*
6 oz salt (weight) I would use Celtic Sea Salt or other such salt here
1 oz black pepper (weight)
1 oz olive oil (volume)
Roast onions and garlic in olive oil for approximately 15 to 20 minutes.
Add all ingredients to water, chicken and tomato paste.
Let simmer over medium fire until cooked.
Approximate yield is 640 ounces or 5 gallons.
*We used a ton of diced Roma tomatoes in the restaurant for just about everything. We removed the pulp from these tomatoes before dicing them. We saved the pulp and used it in the stock.
*Here in Spain I have discovered a wonderful way to drink wine and stay hydrated. They have a drink called Tinto de Verano (see photo at top), which is half fruity Spanish wine and half sparkling water poured over ice with a slice of orange and slice of lemon thrown in. It's kind of sangria lite. Each time you drink a glass of it, you get half wine and half water, so you rehydrate the water lost from the little alcohol in the half glass of wine. It's tremendously refreshing, and I've drunk my weight of it since arriving.
This article is just in time for me as it addresses some of the problems I have been going through with the low-carb diet. I need more water and good salt.