Friday, April 19, 2019

Weekly Link Love — Edition 25

Research of the Week

Statins linked to diabetes, again.

A ketogenic diet helps relapsing MS patients lower fatigue, reduce depression, and lose weight.

Indigenous Australians traded pottery with Papua New Guineans for thousands of years.

A fatty liver epidemic in young people is bad news and simply shouldn’t be happening (but is).

Narcissists make better citizens.

New Primal Blueprint Podcasts

Episode 328: Dr. Loren Cordain: Host Elle Russ chats with the creator of the original Paleo Diet, Dr. Loren Cordain PhD.

Episode 329: Dr. Lindsay Taylor: Host Brad Kearns chats with Dr. Lindsay Taylor, PhD and co-author of the Keto Passport.

Health Coach Radio Episode 8: Kama Trudgen: Kama Trudgen runs health retreats for the indigenous Yolngu people of Northeast Arnhem Land, Australia, helping them reclaim health using traditional diets and lifestyle practices.

Each week, select Mark’s Daily Apple blog posts are prepared as Primal Blueprint Podcasts. Need to catch up on reading, but don’t have the time? Prefer to listen to articles while on the go? Check out the new blog post podcasts below, and subscribe to the Primal Blueprint Podcast here so you never miss an episode.

Media, Schmedia

Not grazing on junk all day long is “starving,” apparently.

Irish soil contains microbes that fight drug-resistant bacteria.

Interesting Blog Posts

Ancient animal urine could reveal the history of animal agriculture.

A sandwich with pickles instead of bread? Sure, why not.

Social Notes

Enter now to win a Cuisinart Airfryer, $200 in Primal Kitchen loot, and a $100 gift card to PrimalKitchen.com.

My quick, effective road workout when I’m traveling light without gym access.

Everything Else

This seems like a good use of GMO technology: blight-resistant American chestnut.

Google pulls the plug on its glucose-monitoring “smart lens” they’d been working on since 2014.

Raw eggs in milk, carrots, steak, lamb chops, liver, and the odd ice cream sundae: Marilyn Monroe’s diet.

Things I’m Up to and Interested In

Virtual health summit you should attend: Habits to Thrive, a 7-day summit hosted by Deanna Wilcox, Anya Perry, and 17 other Primal Health Coaches.

Study I found interesting: Drug and alcohol use and life satisfaction.

Positive side effect I’m hoping develops: Scientists are mad that T-rex bones are going for millions on eBay rather than remain in the public trust. But what if high prices and private sales spur more finds and more discoveries?

I think there are better ways to lose weight: Than swallowing 3-dimensional cellulose matrix tabs that expand in your stomach and take up space.

I can’t think of a better way to gain weight: “…eating behaviors of modern consumers may be guided by a predominant goal to attain the subjective experience of complete fullness.”

Question I’m Asking

Some high-end coffee places are banning milk, sugar, and cream, arguing that the extra additions detract from the true coffee experience. What do you think of food establishments with draconian policies like that—snobs or real artisans?

Recipe Corner

Time Capsule

One year ago (Apr 14– Apr 20)

Comment of the Week

“What about a half scoop of metagenics thermaphaseprotein detox powder in water? Will this break my fast?”

– Depends which ThermaPhase tier you’ve reached. Tier 2 and below you’d better go a quarter scoop if you want to maintain the fast. Tier 3 ThermaPhase or higher actually extracts calories from you.

collagenfuel_640x80

The post Weekly Link Love — Edition 25 appeared first on Mark's Daily Apple.



from Mark's Daily Apple http://bit.ly/2GzqjtD

Baby It’s Cold Inside

Hyacinth flowers in the birch pot Thomas bought last fall are bringing all the springy feels to our dining room this week. The flowers smell sooooo good too! See those little egg bites up there? I have a post coming up about them. They are easy, quick and delicious – the best combo for a recipe!

Baby It’s Cold Inside

You know how sometimes it gets warmer outside than it is inside? That effect was strong all week, and I often found myself going outside to warm up! Inside, however, I had on two jackets, including my Luxe Hoodie ( <– on sale!) which reminds me of something Jon Snow would wear with all that fur up there!

Occasionally I Eat Reese’s

One reason I like shopping at Whole Foods is that I don’t have the temptation of junk food. Yes I am tempted by certain things, Oreos and Reese’s are two of my favorite not-so-real foods. (I have zero temptation to eat Doritos or swing through drive thrus though.) I went into Kroger on the way home from my soccer game on Sunday to pick up some chicken broth for our dinner recipe. While in there I passed the Easter candy aisle. Mind you I had just played two hours of soccer and was STARVING so that did not help! I bought the boys some Easter basket goodies and came out with this bag of Reese’s Pieces eggs – big ones – that I just had to try. OMG – so good.

Sunny Soccer

Mazey had a soccer game on Monday and we were treated to bright blue skies. (It poured down rain during my Sunday game – I can’t remember the last time I got rained on like that!) He scored two goals!

B. Good

Afterwards, we went to B. Good for dinner! They invited us to come on the house, and we had a great little family meal. Did you know kids eat free on Tues + Thurs? What a great deal. And if you can see Mazen’s kids meal back there, it came with a hot dog, a few fries, broccoli, and applesauce. I’d call that a pretty good kids meal to get for free. (And Mazen even ate his broccoli!)

I had the Spicy Lime and Avocado bowl (half) and the Power Play burger (half), shared with Thomas. B. Good focuses on locally sourced ingredients and humane meats, so we will be back again soon.

Boys Will Be Boys

Birch had a playdate this week with his friend H who is just a few weeks younger. Don’t they look a little alike? Similar eyes, same cheeks. Boys gotta be tough, they say!

Fresh Faced

You guys, I swear I’ve already noticed a difference in my skin after using the Beautycounter products for a week. It seems more glow-y and even. I could be biased though, so I will keep waiting and we will let the photos speak for themselves.

I had Emily take some before photos of my face. Now that was awkward! My nose zoomed in 1000%. Here’s me with zero make up on, no filter, unedited. We can compare in a few weeks!

And here’s me with most of my Flawless In Five on! (Tint Skin in Linen // Concealer in light // Blush in Melon // Lengthening mascara in black // Brows in light // + Color Intense Lips in 9 to 5) I really love how fresh and natural the makeup looks.

Workouts

I finished my iFit French Polynesia program this week! I really do think I gained running ability from the start to finish. Running at 8.0 felt like a full on sprint when I started – I felt like I was going to fall off the tread! But by the end it felt like a fast run. I’d say that’s improvement! I also went to strength class on Wednesday. Feels good to be back!

Pre workout breakfast. And after: a banana with PB!

I love my ponytail after it spends a night in a bun 🙂

Meals

I’m still eating quiche (and pita chips) all the time! It’s been my favorite part of Plenty because it’s perfect for both lunch and dinner.

Thomas brought me a Bodos bagel for lunch one day – the usual with salmon, cream cheese, sprouts and cucumbers. If you can’t tell, this one was super light on cream cheese and just was not up to par! Cream cheese is to a bagel as frosting is to cake. The cream cheese to bagel ratio must be at least 1:1 :mrgreen:

This meal from Plenty was 100%! Shrimp, sausage, and veggies over polenta.

We also LOVED the beef enchiladas! With a homemade side salad. These might have been the best homemade enchiladas I’ve ever had.

And for dessert – my sticky little gumdrop! I love how much he loves books.

Have a great weekend and a Happy Easter!

The post Baby It’s Cold Inside appeared first on Kath Eats Real Food.



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Episode 424 – Q&A with Robb and Nicki #17


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Here we are with Episode 424, Q&A #17!

If you want to see the video for this podcast, be sure to check out our YouTube channel.

Show Notes:

1. [1:43] Lake vs Chlorinated Pool?

Jocie says:

Hope you and Nicki do another Q&A soon, those are my favorites!

Heading towards summer- I’m wondering what your opinion is on lake vs typical chlorinated pool for summer fun?  Our family opted for the lake last summer, and it was beautiful but between the dead fish and the posted high fecal count, I was more than a little grossed out.  There is a lot of talk about kids growing up healthier when they are exposed to more dirt and germs, but what about things that can mess you over like parasites and giardia?  The chlorinated pool is looking better this year!

2. [4:12] Keto & Endurance (specifically running)

Rick says:

Hey Robb and Nicki,

Thanks for the Q&A episodes – they’ve been super fun. I’m writing to ask you a question about running when I’m on Keto. I’m 45 y/o, male, 6’0″, 235lbs, roughly 30% BF. I’m trying to lose some weight as the primary goal, but I love running too. My ideal workout regimen is to lift 2x per week, full body barbell-type stuff, and run 3-4 times, with runs anywhere from 4-10 miles. I’ve never been fast, but I’ve got pretty decent endurance.

Keto seems to be the absolute best way to lose weight, but I find that my runs really tank. I use a HR meter, and I go about a minute per mile slower and my HR is 10-20 beats per minute higher. The longest I’ve been able to maintain keto is about 5 weeks, and the main reason I fall off the wagon is this. While I’m not weighing and measuring, I am more or less following the suggestions from the Masterclass and Ketogains, and I’m focusing on getting enough electrolytes.

So what do you think is going on? Do I just have to keep plugging? Is it possible I’m not meant to run while keto? How can I speed adaptation? Lots of short slow runs? Fast runs? Slog it out for long and slow? Any advice you have would be fantastic.

Thanks.

Rick

3. [8:26] Carbs for Endurance Once Fat Adapted?

Brian says:

Robb love your insight, 47 year old cyclist typically the last guy on Earth touting low carb eating regiment, but ive been Keto over a year and have seen performance increase against my age. I presume my body has undergone a metabolic shift in fuel source, its working for me! my question is should us endurance guys still carb load to have glucose present in long events or should calorie consumption prior to long events stay parallel to our every day eating regimnet? In others words once this metabolic shift occurs in the macro perspective of ones nutrition is it assumed that the best fuel choice during ultra events should be the same? Would re-introducing glucose be a safety net or waste of calories in your opinion?

4. [14:01] High Fasting Blood Glucose on Low Carb/Keto Diet

Heather says:

HI Robb & Nikki!

I’m a HUGE fan and appreciate all of the knowledge and insight you share on the podcast and everywhere else you show up. 🙂 I have eaten low-carb/keto/paleo-ish for several years now, and have done really well. I probably get less than 100g carbs/day (more like 50g), and eat an average of 100g protein/day (grassfed meat, bone broth protein, whey protein smoothies, nuts/seeds, pastured eggs, mackerel/sardines, and occasionally chicken). My fat intake is probably 90-100g/day. I am 43 yrs old, 5’4 at 118lbs with less than 20% body fat. I go on long walks daily, weight train 3/week, and throw some HITT training along with boxing in the mix. I used to be a spinning instructor and spent hours and hours on the bike each week, but haven’t taught in 4 yrs and now only power walk for “cardio” outside of interval training at the gym. I have two kids, ages 4 & 8, so they keep me busy as well!

I recently (as in 2 weeks ago) bought a blood glucose meter after giving in to my curiosity as to just what my fasting BG is, along with post-prandial, post exercise, etc. I was shocked and so upset when I took my first reading one morning and it was 106!!! Since then I’ve been rather obsessed and am pricking my finger all day long! LOL! But really no matter if i’m fasted, just went on a long walk or weight training session, or even 2 hrs after a meal, my blood glucose is always somewhere btwn 90-110–I never get a big swing upward after a meal, even after I indulged in gf German Chocolate cake the other night! 🙂 It has only gone as low as 83 or 87 on two, random occasions, which is making me wonder, “What the heck?!”

I’ve read different things online about this, but I really don’t know who to trust other than you. Could it be cortisol? Could that be my norm? I was expecting my FBG to be around 70-80 based on my diet and activity level. Please advise! I’m so confused!! Thank you SO MUCH for all you do!!!!! 🙂 🙂 🙂

5. [18:21] Reliability of Glucose Meters

Pedro says:

Dear Robb

My name is Pedro Escudeiro and I am portuguese. I have been following your work through interviews and your online publications and books. I take many notes from your teachings and have been applying them in my own life, which I deeply thank. However, a few issues have arised especially concerning the use of glucometers to measure blood glucose, for metabolic control (fortunately I have no diseases). I would like to ask you a few questions.

For a year now that I use regularly a Freestyle Precision Neo device and the readings are not reliable at all. I have made many experiments, such as trying to prick my fingers 5 times in a row to observe the results. The readings are always different, sometimes 15 or more points (mg/dL). I have done the carb test as well, reproducing the same conditions and the readings also change if I test a few times and in different days. I have tried different devices too. I contacted the company to expose this issue and they told me that it is acceptable a variation of 20 points. Being so, it basically means we can’t rely on this method to inform us on how the body is reacting to foods or to check glucose stability, for example, because it is always changing within the same conditions. I wonder if you have noticed this same issue and if you found a method to overcome this unreliability.

I have used also a Freestyle Libre device, which measures continually the glucose (interstitial fluid) I know there is a delay between the readings and the actual glucose level and there is also less precision than a blood glucometer. However, the same issue of unreliability is happening. The profile of the Libre does not have any match with the blood glucometer or even any correlation, one might be going up and the other down and later one changes and the other doesn’t.

Since glucose levels are so important for health and performance, if the best method to check it is not reliable and trustworthy at all, it makes all the assumptions and decisions about our health, not just worthless but somehow dangerous. I wonder if you have any thoughts on this.

I hope I am not taking too much of your time and I thank you in advance.

My best wishes,

Pedro

 

 

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Transcript:

Download a copy of the transcript here (PDF)

Robb: Welcome back, wife.

Nicki: Welcome back.

Robb: What’s new?

Nicki: I have nothing to say.

Robb: Man, we are an exciting bunch. If anybody still listens to this thing, I’m a little bit shocked.

Nicki: It’s gray.

Robb: It is gray.

Nicki: It’s gray outside. I’m ready for spring.

Robb: Yep, kind of running on low; low sunlight effect.

Nicki: Yeah. I’m reading the Wings of Fire series to Zooey and we’re on the third book and it’s about the RainWing dragons who live in the rain forest, and they recharge by sleeping for many, many hours in the sun. I find myself wishing that I was a RainWing dragon.

Robb: Well, maybe you are but we just have no sun to recharge.

Nicki: Yeah, that might be it. All right. I guess we’ll jump into the first question.

Robb: Yep.

Nicki: Let’s see. Question one is from Josie, and she says, “I hope you and Nicki do another Q&A soon. These are my favorites. It’s heading towards summer and I’m wondering what your opinion is on lake versus typical chlorinated pool for summer fun. Our family opted for the lake last summer and it was beautiful, but between the dead fish and the posted high fecal count, I was more than a little grossed out. There is a lot of talk about kids growing up healthier when they are exposed to more dirt and germs, but what about things that can mess you over like parasites and Giardia? The chlorinated pool is looking better this year.”

Robb: Man, that’s a tough one. That’s kind of why … and this doesn’t answer the question specifically, but, like, going to the ocean, and now the ocean you can get, like, fecal contamination there. But in general, if the stuff gets … dilute enough, most of the bacteria that would be problematic is killed. It doesn’t really live in the saltwater that effectively. But, I don’t know, this is … Lakes are great, I guess. I don’t know.

Nicki: I don’t know. We grew up going to a lot of … we grew up doing both. Like, we’d go to the lake as frequently as we could, and then we’d … I mean, it was Brandy Creek, Whiskeytown Lake had Brandy Creek, which I’m sure has fairly high fecal count.

Robb: Well, you know what’s funny? When we grew up, I don’t know that that stuff did quite the way that it does now. Like, populations have just grown, and people are just dumb, and dirty. “Well, shit, Billy Bob. Let’s go take a dump in the creek here.”

Nicki: You think moreso than-

Robb: I don’t know. I don’t know. I mean, just some of those areas were pretty remote.

Nicki: We also had a pretty gross experience at the kiddie pool at one of the local pools here in Reno. I won’t say exactly what we found floating in it.

Robb: Well, it was a feminine hygiene product.

Nicki: Yeah, you could say it like that.

Robb: Ugh … Yeah, it was horrible.

Nicki: Yeah, in, like, the three-foot water kiddie pool. So I think you’re kind of-

Robb: Kind of damned if you do, damned if you don’t. Now, in that scenario, in theory, the chlorinated water killed everything in there at least. But, ugh, yeah. Yeah, definitely the big win is to have a pool in your backyard basically.

Nicki: Oh, man. Yeah.

Robb: Do a saltwater pool in your own backyard and then you’re cool. And make sure all the neighbor kids are threatened with death if they take a dump in your pool.

Nicki: Okay. Let’s see. Next question is from Rick on-

Robb: Right. Keto and endurance?

Nicki: Keto and endurance, specifically running.

Robb: We skipped the last one.

Nicki: I didn’t read the title.

Robb: We didn’t read the title. Yeah, sorry.

Nicki: I have five demerits. Okay. So Rick says, “Thanks for the Q&A episodes. They’ve been super fun. I’m writing to ask you a question about running when I’m on keto. I’m 45 years old, male, 6 foot tall, 235 pounds and roughly 30% body fat. Trying to lose some weight is the primary goal, but I love running, too. My ideal workout regimen is to lift two times per week, full-body barbell-type stuff, and run three to four times with runs anywhere from 4 to 10 miles. I’ve never been fast, but I’ve got pretty decent endurance.” Let’s see. “Keto seems to be the absolute best way to lose weight, but I find that my runs really tank. I use a heart rate meter and go about a minute per mile slower than my heart rate … is 10 to 20 beats per minute higher.” That didn’t really-

Robb: He goes slower and his heart rate gets higher, yeah.

Nicki: “The longest I’ve been able to maintain keto is about five weeks, and the main reason I fall off the wagon is this: while I’m not weighing and measuring, I’m more or less following the suggestions from the masterclass and Ketogains, and I’m focusing on getting enough electrolytes. So what do you think is going on? Do I just have to keep plugging? Is it possible I’m not meant to run while in keto? How can I speed adaptation? Lots of short slow runs, fast runs, slog it out for long and slow? Any advice you have would be fantastic.”

Robb: Yeah, so reading between the lines here, a couple of different things: are you for sure 100% unequivocally hitting your electrolyte levels? I thought I was and I wasn’t. And in theory, I’m an expert on this stuff. But Tyler and Louise, each time I came back to them talking about jujitsu and other issues they were just like, “Electrolytes, electrolytes,” and ultimately that ended up being the big deal. So that’s a glaring thing here. Yeah, it just popped up again and again and again.

Robb: So the low-hanging fruit is really making sure that you’re getting a minimum of five grams of sodium a day plus the other electrolytes. You’re a bigger dude, so you might even need a little bit more than that. Depending on the heat and humidity of the area that you’re in you might need even more. That’s one thing.

Robb: The other thing is that, in general, keto adaptation takes about four to five weeks. You are slogging through the hardest part, and then stopping at just about the point that all the research suggests that we should get our VO2 max back and we should at least be able to do aerobic-paced activities.

Robb: So I would say, yeah, you probably need to … A couple of different things: if you want to stick with specifically keto, you’re going to have to motor a bit longer, really make sure that you’re on point with the electrolytes, and I would give it a full eight weeks to make sure that you’re fully adapted to that.

Robb: The other thought is that you don’t have to be keto to lose weight. It’s effective, and it’s effective in part because of the appetite-suppressing kind of characteristics, but there’s this whole thing of low-carb and paleo and stuff like that, you know, people motor along quite well with those approaches.

Robb: It’s kind of funny. For ages, I would search for “Brazilian jujitsu ketogenic diet”, “optimal diet on Brazilian jujitsu”, and what was really funny is the kind of … the thing that came back … the vegan diet actually came back fairly frequently, but in general it was, “Man, this paleo diet is awesome for Brazilian jujitsu.” But this is paleo as in eating sweet potatoes and fruit and all that, that type of stuff, not like a super low-carb iteration of it.

Robb: So, yeah, hang in there if you want to. Slog it out for at least eight weeks. Make damn certain that you’re on point with your electrolytes. Then, from there, if things are just really not clicking over, focus on the appropriate amount of protein, get low glycemic load carbs and titrate those up to the point that you actually get your performance back.

Nicki: All right.

Robb: Or start Brazilian jujitsu, because it’s awesome.

Nicki: Okay. Our next question is from Brian, “Carbs for endurance once fat adapted. Robb, I’d love your insight. I’m a 47-year-old cyclist, typically the last guy on Earth touting a low-carb eating regimen, but I’ve been keto over a year and I’ve seen performance increase against my age. I presume my body has undergone a metabolic shift in fuel source because it’s working for me. My question is, should us endurance guys still carb load to have glucose present during long events, or should calorie consumption prior to long events stay parallel to our everyday eating regimen? In other words, once this metabolic shift occurs in the macro perspective of one’s nutrition, is it assumed that the best fuel choice during ultra events be the same? Would reintroducing glucose be a safety net or a waste of calories in your opinion?”

Robb: Man. So the first caveat here is I am absolutely not an endurance coach. I watch this stuff from afar. It’s not in my wheelhouse. So take that with a huge grain of salt, five-gram grain of salt.

Robb: I’ve seen this work all over the map. In general, the benefit of a low-carb-fueled athlete is that he or she will need less in-event fueling than what somebody else would, a more carb-centric individual.

Robb: Marathon doesn’t really seem to matter that much if you’re really fast, because the marathon … those dudes are running so fast, and they get it done in about two hours, which is kind of the outer edge of what one’s glycogen stores are, so the people who typically hit the wall in marathoning do it because they run slow enough such that they end up depleting their muscle glycogen and they’re not adequately fat-adapted. So if you’re real fucking fast and the duration isn’t that long, then even the glycogen stores from keto adaptation will kind of motor you through that for the most part.

Robb: I have absolutely seen folks do the sweet potato or rice the day before an event, and that works well for some people. Peter Defty over at Vespa, OFM, Optimum Fat Metabolism … he’s an endurance coach, a legit endurance coach; has a lot of people under his tutelage. They do a couple of different strategies. They will do the day before doing higher carbs so that you get some top off. Other people simply use some goo or some other things, but they’re able to use it pretty selectively, because they are running more on a fat-adapted kid of plateau or process.

Robb: I’m trying to think of any other offerings there. Joe Friel is a great coach, Peter Defty, Elijah Markstrom. And I’m thinking back to the question that we just asked a moment ago. Elijah Markstrom is a really well-known kind of Spartan race athlete. He noticed that being purely ketogenic was problematic. What he experienced was it was almost like he had a governor on his heart rate. Like, he would try to push hard, but his heart rate would be much higher, fully keto-fueled, versus even doing 100, 120 grams of carbs. At a given power output, his heart rate would be, like, 10 to 20 beats less, which is huge; like, make or break a scenario.

Robb: So I’ve seen a lot of different strategies on this stuff and it’s just all up for the tinkering. Potentially, I would reach out to some of the people that I’ve mentioned, maybe nose around some of the other low-carb or peri low-carb endurance coaches and maybe have them kind of take you under their wing for some period of time so that you can help get that stuff dialed in.

Robb: But my sense is definitely that there’s not a one-size-fits-all approach to this. It’s really dependent on, man, a ton of different variables: the duration of the event, how fat-adapted you are; again, shorter events like a sprint, triathlon, and I think they mentioned ultra events-

Nicki: A cyclist. I don’t think … Yeah, ultra events. Yeah.

Robb: Ultra events. I mean, real long stuff. People do still use carbohydrate during those events, like Sami Inkinen, who’s a cofounder of Virta, he did a pretty interesting blog post talking about a really epic bike ride that he did, and he ended up consuming 150, 200 grams of carbs throughout the course of that day, but was also tracking his ketone levels and he was ketogenic the whole time because of the work output.

Robb: Yeah, man. I wish I had a more concrete answer for you, but this is where working with a coach, or if you’re going to put this stuff together you kind of just need to establish a baseline and then pressure test it and see how things do. Then, A/B test variables: “I added pre-workout carbs: these things happened. I added intra workout carbs: these things happened. I added intra workout carbs plus an NCT oil and I pooped my pants.” That thing happens. So you just kind of have to get in and tinker with it.

Robb: Again, some of the really well-established endurance coaches may have a much better kind of algorithm that they move through it. But I understand that stuff in theory, not in practice.

Nicki: All right. Our next question is from Heather on having a high fasting blood glucose level on a low-carb keto diet. “Hi Robb and Nicki. Huge fan, and appreciate all the knowledge and insight you share on the podcast and everywhere else you show up. I’ve eaten low-carb paleo-ish for several years now and have done really well. I probably eat less than 100 grams of carbs per day, more like around 50, and eat an average of 100 grams of protein per day: grass-fed meat, bone broth protein, whey protein smoothies, nuts, seeds, pastured eggs, mackerel, sardines, and occasionally chicken.

Nicki: My fat intake is probably 90 to 100 grams per day. I’m 43 years old, 5’4″ at 118 pounds with less than 20% body fat. I go on long walks daily, weight train three times a week, and throw some hit training along with boxing in the mix. I used to be a spinning instructor and spent hours and hours on the bike each week, but haven’t taught in four years and now only power walk for cardio outside of interval training at the gym. I have two kids, ages four and eight, so they keep me busy as well.

Nicki: I recently, as of two weeks ago, bought a blood glucose meter after giving into my curiosity as to just what my fasting blood glucose is, along with postprandial, postexercise, et cetera. I was shocked and so upset when I took my first reading one morning and it was 106. Since then, I’ve been rather obsessed and am pricking my finger all day long. But really, no matter if I’m fasted, just went on a long walk or weight training session, or even two hours after a meal, my blood glucose is always somewhere between 90 and 110. I never get a big swing upward after a meal, even after I indulged in gluten-free German chocolate cake the other night. It has only gone as low as 83 or 87 on two random occasions, which is making me wonder, “What the heck.”

Nicki: I’ve read different things about this online, but I really don’t know who to trust other than you. Could it be cortisol? Could that be my norm? I was expecting my fasting blood glucose to be around 70 to 80 based on my diet and activity level.

Nicki: Please advise. I’m so confused. Thank you so much for all you do.”

Robb: So I think last week’s podcast we kind of had something similar to this where the individual had kind of higher blood glucose levels than what they might think.

Robb: The way that we tackle this is what I call triangulating in on this. So we have a blood glucose level that’s being tested at various points that looks higher than what we potentially would look. So then we look at the A1C and see what that looks like. And I would recommend just getting the fructosamine at the same time. If the A1C is also elevated and fructosamine is also elevated, then that means we have across the board elevated blood glucose levels. If fasting blood glucose or blood glucose in general as checked by a finger stick or even a CGM is high and A1C is high but fructosamine is low, then we’ve got some other things going on, like red blood cells living longer because of being on low carb and stuff like that.

Robb: Let’s assume that it’s the drizzling shits and blood glucose is higher than what we would like. A couple of things we can look at. One, is making sure that you’re on point with electrolytes. We know for a fact that inadequate sodium intake and electrolytes in general is an adrenal stress and people getting on point with the electrolytes ends up dropping heart rate, it drops cortisol levels, it tends to drop blood glucose levels. So I would make damn sure that you’re on point with the electrolytes.

Robb: If that doesn’t address things to the degree that you would like, then we start asking the question around, “Maybe you would do better at that 150 grams of carbs a day. Maybe a little bit more on heavier training days, a little bit less on sedentary days.” But that’s kind of the way that I would tackle this.

Robb: First, I would do a little bit of additional testing to figure out, like, “Really, what do you have going on? Is it concerning? Is your A1C and your fructosamine elevated in such a away that we would be concerned about that? If it is, then the things to really tinker with are making damn sure that you’re on point with your electrolytes, specifically sodium. If that doesn’t address things, then I would definitely get in and tinker with just reintroducing more carbs and see how you do with that.

Robb: Any other thoughts, wife?

Nicki: No, I don’t think so. Good question, Heather.

Nicki: Let’s see here. Well, and it also ties into this. But if she’s consistently getting … if every day she’s getting in that range then it’s probably not glucose measurement reliability, which is the next question.

Robb: Which is the next question, yeah.

Nicki: From Pedro. “Dear Robb, my name is Pedro and I’m Portuguese. I’ve been following your work through interviews and your online publications and books. I take many notes from your teachings and have been applying them in my own life which I deeply thank you for. However, a few issues have arised, especially concerning the use of glucometers to measure blood glucose for metabolic control. Fortunately, I had no diseases.

Nicki: I would like to ask you a few questions. For a year now, I’ve been regularly using the FreeStyle Precision Neo device and the readings are not reliable at all. I’ve made many experiments, such as trying to prick my fingers five times in a row to observe the results. The readings are always different, sometimes 15 or more points-“

Robb: Milligram per deciliter.

Nicki: “Milligram per deciliter. I’ve done the card test as well, reproducing the same conditions, and the readings also change if I test a few times and in different days. I’ve tried different devices, too.

Nicki: I contacted the company to expose this issue and they told me that there is an acceptable variation of 20 points. Being so, it basically means we can’t rely on this method to inform us how the body is reacting to foods or to check glucose stability, for example, because it’s always changing within the same conditions.

Nicki: I wonder if you have noticed the same issue and if you’ve found a method to overcome this reliability. I’ve also used a FreeStyle Libre device, which measures continually the glucose, interstitial fluid. I know there’s a delay between the readings and the actual glucose level and there’s also less precision than a blood glucometer. However, the same issue of unreliability is happening.

Nicki: The profile of the Libre does not have any match with the blood glucometer or even any correlation. One might be going up and the other down, and later one changes and the other doesn’t. Since glucose levels are so important for health and performance, if the best method to check it is not reliable and trustworthy, it makes all the assumptions and decisions about our health not just worthless but somehow dangerous. I wonder if you have any thoughts on this?” My best wishes, Pedro.”

Robb: Yeah, it’s a great question, and this is something that was pretty frustrating when we were kind of rolling out the Seven-Day Carb Test, when I became aware that there’s about a 20% error in the basic testing in most of these glucometers. I forget, there are some that the error rate is claimed to be around more like 5%. I forget which one that that is.

Robb: But if you have a 20% error rate, if your true blood glucose reading is 100, we would not really be surprised if it was as low as 80 or as high as 120. This is why in addition to the testing I recommended this whole matrix of, “How’s your cognition? How’s your digestion? What’s your kind of sense of inflammation?” So that we could, again, kind of get multiple … as hard a data as we could, and then shift a little bit into the softer data, you know, just how you’re feeling and the performance and whatnot.

Robb: And I don’t have a super good answer to this. The error kind of bars in this story are pretty big. This is why I recommend that folks use it as a guide to kind of point them in a particular direction, but we can’t get overly hung up on this.

Robb: I remember when Nicki did this stuff … What was it? Your blood glucose ended up, like, two points lower after … so you had a baseline, and then it went to its high, and then it-

Nicki: And then it dropped low and [crosstalk 00:22:05]-

Robb: So it started at, like, 75, and then it went to 105, and then it went to 73. And people were like, “You have phase 3 craft pattern,” or something like that. And I’m like, “Fucking horseshit, people.” Like, the error … You’re trying to ascribe a three-point delta between the initial and the final test when there’s a 20-point error bar encompassing this whole thing, and I’m not a statistician, but this is where people almost get overeducated to the point of being dangerous, where, like, you can’t pull back and look at this stuff with a little objectivity.

Robb: I think as time goes on these instruments will get better and better. I will do some poking around and … I remember when we were kind of thick into the Wired to Eat stuff there were one or two brands that were significantly better with regards to error rate, like, it was more an established, like, 5% error. But this is, again, also where doing the occasional A1C and also the fructosamine, you can use that to just kind of triangulate in on that stuff.

Robb: Then, also, finally, I’m just not a fan of people tracking this stuff every day all the time. I know some people do, they’re just kind of data geeks. But Christopher Kelly over at Nourish Balance Thrive was talking about this stuff, not just with regards to CGMs, but heart rate variability monitors and power output monitors when you’re riding your bike and stuff like that. Some of it’s really valuable, and sometimes it’s kind of the difference in being able to click over performance and really make the next step in what you’re trying to do. And a lot of it is just a distraction. Like, you’re spending all this time trying to pair Bluetooth devices to this, that and the other, instead of just kind of doing what you need to do.

Robb: We were talking this morning about the HRV stuff, because we’re tinkering with some meditation material-

Nicki: Right. There was some article that Tyler shared with us that was talking about how some of these devices are … there’s enough error rate within them, but then there’s this placebo effect that happens, a negative placebo effect. So if, for example, if you’re wearing something and it tells you that you had a really poor night of sleep, maybe you did, maybe you didn’t. If it wasn’t measuring you accurately, maybe you had a decent night of sleep but it says you had a poor night of sleep; that people actually … the rest of their day they internalize that and they really feel like they had a really terrible night of sleep.

Robb: And it kind of cuts both ways. Like, sometimes they actually didn’t sleep well but the HRV says they’re on point, and then they rally and they do okay. Then, to Nicki’s point, there’s times where it’s just kind of a weird error or artifact. Like, when we were tinkering with one of the platforms, I would lay down to read and it would say that I … it would give me a super shitty ready because it said that I had a latent sleep process, which wasn’t the issue at all.

Nicki: Right, you were just laying in bed reading.

Robb: Yeah, I was just laying in bed reading, and I had my [inaudible 00:25:05] on, and we go to bed when everybody else is still, like, fucking eating dinner and stuff like that. So I’m like, “Give me a break,” you know? And I could never get this thing to give me better than, like, a mid-80s, and heading towards 100. And I was like, “What else am I going to do to make this thing better?”

Robb: So it became kind of annoying at some point and I think maybe wearing a platform like that, and I know we’re just wandering all over the place now, but a platform like that in my 20s when I would work myself to the bone then maybe that would be helpful.

Robb: But, yeah, this is where the testing stuff, it’s valuable, but you’ve got to really have good context with it and, man, it’s a narrow window of the information that we have. And being aware, which it sounds like Pedro is very aware of the limitations of what this stuff can tell us and keeping that in proper context, for sure.

Nicki: Great. I think that was our-

Robb: Was that the last one?

Nicki: Final question for this week.

Robb: Quick and dirty.

Nicki: Yep. So if you guys have questions you can submit them on RobbWolf.com at the Contact page.

Robb: Follow us on Instagram-

Nicki: Instagram-

Robb: @DasRobbWolf.

Nicki: YouTube. Anything else?

Robb: Paleo f(x) coming up, FitCon coming up. Not sure when this one is dropping, so it may be done by the time-

Nicki: No, this will come out before Paleo f(x).

Robb: Okay, okay, cool.

Nicki: Awesome. Thanks, guys.

Robb: Bye.

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Thursday, April 18, 2019

The Friday 5

Hi, friends! Happy Friday to you!

So, we’ve had quite the fun April vacation week. We got back from New York City on Monday morning, which, of course, was a great way to kick off the week. On Wednesday, I filmed a donut review with Jack from The Donut Digest at my beloved Coffee Shack.

The location closer to our home went out of business, but the original Coffee Shack is alive and well (in Marshfield). It’s about 30 minutes away, so I don’t often visit. But when I do, it’s a special occasion! 🙂

Jack gave the honey dip a B- grade, but the coconut donut is a solid A for me! 🙂

And the iced coffee is THE BEST around. Check out all of the fun flavors, which are brewed from flavored beans, not sugary syrup. Coffee Shack even has flavored decaf iced coffee! 🙂

Yesterday, Mal and I went to the driving range and then enjoyed a little happy hour action before picking up Quinn from school. My new fitness endeavor is learning how to play golf this summer, so it was a great start to this new project. I actually hit some decent balls!

All in all, it was a fun vacation week. And now that it’s Friday, it’s time for another edition of The Friday 5 where I recap my 5 favorites from the week. Enjoy!

1. Jeni’s Ice Cream– Omgggggg. Our NYC friends bought this ice cream for us to try one night (well, ok, both nights we visited because we loved it so much), and it’s absolutely incredible. The Gooey Butter Cake was out of this world! OMG. And if you go onto the website you’ll see that the Jeni’s flavors are truly something else. We found Jeni’s pints at Murray’s Cheese, but it looks like they’re in some Whole Foods locations and available online. I’m definitely planning a trip to our local Whole Foods this weekend! 🙂

2. Beautycounter Brilliant Brow Gel – Gals, full brows are in, which is why I love the new brow gel from Beautycounter. I don’t have very full brows, so I love that this fills them in while still looking natural. It’s like a mini mascara wand that colors the brow hairs, not the skin. I went with soft black, but it comes in 5 shades including clear. Photo: before on the left/after on the right. It’s subtle and natural-looking, but makes a difference!

3. Almond Joy Chia Pudding – I dug out this oldie but goodie recipe (if you haven’t tried chia pudding, you’ve gotta try this recipe with almonds, coconut, and chocolate!). This recipe is perfect to make a double batch of at the start of the week (add collagen for added protein) to have on hand for the easiest grab-n-go breakfast, snack, or dessert! Plus, it’s packed with protein and healthy fats!

4. Butcher Box Breakfast Bundle – It’s no surprise that we love Butcher Box in our house, so I was really excited to hear that when you sign up this month you get a free Breakfast Bundle that includes 2lbs of pork breakfast sausage and 2 packs of bacon (yes, you get all of that for FREE!). The uncured bacon (free of sugar, nitrates, and hormones is made from pasture raised heritage breed pigs) pairs perfectly with our favorite paleo pancakes. And the sausage can be used in a bunch of meal prep recipes. We’re eating less meat nowadays, but when we do, we make sure it comes from high-quality sources. The bacon actually comes from Niman Ranch!

5. Clean-Crafted Wine from Scout & Cellar – This Sauvignon Blanc is light, crisp, and perfect for Spring! The amazing thing about Scout & Cellars Wine is that it is clean-crafted, which means it just includes grapes and less than 50ppm of sulfites.

Some mass-produced wines on the market have as much as 350ppm of sulfites. No wonder I feel like crap in the morning after only drinking a glass or two! Mass-produced wines can also have added sugar or sweetener concentrate, ferrocyanide, ammonium phosphate, copper sulfate, mega-purple, GMO ingredients, and synthetic pesticides. Yikes! This isn’t to say that I’ll never drink mass-produced wine again. I love to have wine out and have drinks with friends, but I will definitely do my best to control the wines that I drink at home!

Sales of the Week

Question of the Day

Do you have a favorite bacon or breakfast sausage recipe?

P.S. Local peeps: There’s a CrossFit throwdown at Salt Shack in Hanover, Massachusetts in June! I’ll be there spectating and chatting about macros, so if you’re into the competition thing, please check it out. This one will be FUN! 

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Keto and the Menstrual Cycle: Is There Reason To Worry?

It seems every “keto for women” forum abounds with stories about menstrual cycles gone wild in the first few months of keto. Irregular cycles, breakthrough bleeding, and periods lasting much longer than normal are common complaints. Sometimes these stories are cited as evidence that keto isn’t good for women, at least not premenopausal women, and that we need carbs for healthy hormones. Yet, many women don’t notice any changes in their menstrual cycles at all, while others report improvement in PMS symptoms and cycle regularity from the get-go.

What gives? Why do some women’s cycles apparently become wacky when they start keto, while others feel like keto is the key to period bliss? Can keto “mess up” the menstrual cycle?

We know that diet—what and how much we eat—can profoundly affect our hormones. This is true for both women and men. One of the reasons people are so excited about ketogenic diets is specifically because keto shows promise for helping to regulate hormones and improve cellular sensitivity to hormones such as insulin and leptin.

At the same time, women’s hormones are especially sensitive not only to dietary changes but also to downstream effects such as body fat loss. Furthermore, one of the ways women’s bodies respond to stressors is by turning down the dial on our reproductive systems. It’s reasonable to hypothesize, then, that women might have a tougher time adapting to or sustaining a ketogenic diet. Keto can be stressful depending on one’s approach, and that might negatively impact women’s reproductive health. But do the data actually bear that out, or is so-called “keto period” more misplaced hype than genuine fact?

Note that throughout this post, I’m going to use the term “reproductive health” to refer to all aspects of women’s menstrual cycle, reproductive hormones, and fertility. Even if you aren’t interested in reproducing right now, your body’s willingness to reproduce is an important indicator of overall health. When your reproductive health goes awry—irregular or absent periods (amenorrhea) or hormone imbalances—that’s a big red flag. Of course, post-menopausal women can also experience hormone imbalances that affect their health and quality of life (and low-carb and keto diets can be a great option for them).

Menstrual Cycle 101

Let’s briefly review what constitutes a normal, healthy menstrual cycle, understanding that everybody’s “normal” will be a little different. A typical cycle lasts from 21 to 24 days on the short end to 31 to 35 days on the long end, with 28 days being the median. Day 1 is the first day of your period and begins the follicular phase, which lasts until ovulation. Just before ovulation, levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol (a form of estrogen) spike. Next comes the luteal phase covering the approximately 14 days from ovulation to menses. LH, FSH, and estradiol drop, while progesterone rises. Estradiol bumps up again in the middle of the luteal phase. If a fertilized egg is not implanted, menstruation commences, and the whole cycles starts over again. All this is regulated by a complex communication network under the hypothalamic–pituitary–gonadal (HPG) axis, which is closely tied to the actions of the adrenal (the A in HPA axis) and thyroid glands.

Across the cycle, fluctuations in body weight are common as fluid is retained and then released along with shifts in estrogen and progesterone. Changes in blood glucose are also normal, and insulin-dependent diabetics often find that they need to adjust their dose at different times of their cycles to keep their blood sugar in check. The most common pattern is higher blood glucose readings in the pre-menstrual period (the second half of the luteal phase), and lower readings after starting your period and before ovulation. This is generally attributed to the fact that progesterone, which is highest during the luteal phase, is known to reduce insulin sensitivity. However, different women experience different patterns, which can also be affected by other factors such as oral contraceptive use.

Normal fluctuations in insulin resistance and blood glucose can mean that women get lower ketone readings at certain times of the month than others. When these occur premenstrually—and so they tend to coincide with a period of (transient) weight gain and food/carbohydrate cravings—women often feel as though they are doing something wrong. Rest assured that these variations reflect normal physiology.

The many factors that affect your cycle and the levels of your sex hormones include: other hormones, gut health and microbiome, metabolic health (e.g., insulin sensitivity), environmental toxins, stress, sleep, immune health, nutrient deficiencies, activity level and energy expenditure, and age. Each affects the others, and all (except age of course) can be affected by diet. It’s no surprise, then, that it can be extremely difficult to pin down a root cause of menstrual changes or reproductive issues.

What the Research Tells Us About Keto and Menstruation

As I said at the outset, there are lots of anecdotes, both positive and negative. In my experience, most women whose cycles seem to go crazy when they start keto find that things get back to normal—and often a better version of normal—after a few months.

First, it’s tricky to determine the effects of keto per se, since many people combine a ketogenic diet with calorie restriction (intentionally to lose weight or unintentionally due to the appetite suppressing effects of keto) and with fasting (intermittent and/or extended). Each of these can independently impact the factors listed above, lead to weight loss, and affect the menstrual cycle and reproductive health.

So, is there any evidence that keto itself causes changes to menstruation?

The scientific evidence is scant….

The one statistic you’ll see floating around the interwebs is “45% of (adolescent) females experience irregular menstrual cycles on keto.” This statistic comes from one small study of adolescent girls using a therapeutic ketogenic diet to treat epilepsy. Six of the twenty girls reported amenorrhea (loss of period) and three were diagnosed with delayed puberty. However, the ketogenic diet used for epilepsy is different and usually much stricter than an “everyday” keto diet needs to be, and epilepsy is frequently associated with menstrual dysfunction regardless of diet.

To extrapolate the findings of this study and argue that nearly half of teenage girls (or women generally) are likely to experience menstrual problems from going keto is a huge leap.

The fact is, I’m unable to find any studies done in healthy human females (or mice for that matter) demonstrating that otherwise normal menstrual cycles are disturbed by going keto.

5 Ways Keto-Related Factors *Might* Affect Your Menstrual Cycle

With the limited amount of research looking directly at keto and menstruation, let’s look first at whether there are direct effects of carbohydrate restriction or elevated ketone production on the menstrual cycle. Those are the defining characteristics of keto and what differentiates keto from other ways of eating. Then we can examine indirect effects that occur due to factors such as weight loss. These are not unique to keto, though they might be more likely on a ketogenic diet compared to other ways of eating.

Carbohydrate Restriction

There is no real body of evidence that looks at ketogenic levels of carb restriction and menstruation, but there are some clues. In this small study, functional hypothalamic amenorrhea (FHA) was associated with dietary fat restriction; women with FHA actually ate non-significantly more carbs than matched controls and nearly identical total calories. Likewise, in this small study, FHA was associated with lower fat intake but no significant difference in carb intake.

This meta-analysis looked at the effect of low-carb (not keto) diets on markers of reproductive health among overweight women. The researchers found four studies that examined effects on menstruation; all showed improved menstrual regularity and/or ovulation rates. Of six studies that looked at levels of reproductive hormones, five reported significant improvements.

Carb restriction also results in decreased insulin production. Hyperinsulinemia and insulin resistance are frequently associated with polycystic ovarian syndrome (PCOS), one of the leading causes of female infertility and a frequent cause of menstrual irregularity. There is currently a lot of interest in using keto to treat PCOS, but only one small study has so far directly tested the effectiveness of a ketogenic diet to treat PCOS, with positive results.

Ketones

No studies have looked at the direct effects of ketones on menstruation.

Weight Loss

Of course weight loss is not unique to keto, but keto can be very effective for weight loss. Some women experience rapid weight loss when first starting a keto diet. Weight loss in and of itself can impact menstruation through a variety of pathways (and, of course, keto isn’t the only way people lose weight). A key way is by reducing the hormone leptin. Leptin’s main job is to communicate energy availability to the hypothalamus—high levels of leptin tell the hypothalamus that we have enough energy on board, which also means we can reproduce. Low leptin can disrupt the menstrual cycle and is linked to hypothalamic amenorrhea.

Body fat loss can also affect estrogen levels since estrogen is both stored and produced in adipocytes (fat cells). While fat loss in the long term will decrease estrogen production, it is possible that rapid fat loss might temporarily raise estrogen levels and can also affect estrogen-progesterone balance. These transient changes in estrogen levels might underlie some of the menstrual irregularities women report.

Stress

Stress can impact the menstrual cycle in myriad ways. Cortisol acts on the hypothalamus and pituitary glands, affecting hormone levels, sleep, immune function, and gut health, to name a few. Diets can be a source of stress, both at the physiological and psychological levels. Keto has a reputation for being especially stressful because it is more restrictive than other low-carb diets, but this can be mitigated by following the Keto Reset tips for women.

Thyroid Function

Thyroid dysregulation is another common cause of menstrual irregularities, and there remains a pervasive belief that keto is bad for thyroid health. Indeed, the thyroid is sensitive to nutrient deficiencies and caloric restriction, and thyroid hormones, especially T3, do frequently decline on keto. However, as Mark has discussed in a previous post, changes in T3 levels might not be a problem, especially in the absence of other problematic symptoms. Moreover, many practitioners now use keto as a cornerstone in their treatment of thyroid disorders.

What Should I Take From These Findings?

The first takeaway: there just isn’t much direct evidence about how keto might affect your menstrual cycle, positively or negatively. We have some studies suggesting that low-carb diets improve some aspects of menstruation and reproductive health, but keto is more than just another low-carb diet. Ketones themselves have important physiological properties, such as being directly anti-inflammatory, which might positively impact women’s reproductive health.

Second, the ways that keto is likely to (negatively) affect menstruation aren’t unique to keto, they’re common to any diet: hormone shifts mediated by energy balance, stress, and weight loss.

Furthermore, since keto is so often combined with caloric restriction, time-restricted eating, and fasting, even the anecdotal evidence might not be able to tell us all that much. If a woman is eating ketogenically, in a big caloric deficit, and doing OMAD (one meal a day), and her leptin plummets, how are we to know what really caused it? We don’t have good evidence that otherwise healthy women start a well-executed ketogenic diet and end up messing up their menstrual cycles.

That said, women do need to be cognizant of the sum total of the signals they are sending their bodies when it comes to energy availability and stress. A lot of women come to the keto diet with a history of adrenal, thyroid, metabolic, and reproductive issues. It’s important that they’re extra careful about how they approach keto. Done correctly, it might be just what the doctor ordered. I encourage any woman who’s dealing with other hormonal issues to work with a medical practitioner to tailor a keto diet to her unique needs.

But I’m Telling You, Keto Made My Period Go Haywire!

Ok, I believe you, really! But changes do not necessarily equal dysfunction. It is normal to experience hormone fluctuations when you make a massive—or even a relatively small but important—shift in your nutrition. Sometimes those fluctuations are unpleasant or unwanted, such as a period that lasts 14 days or one that arrives a week before you planned while you’re on vacation. However, that doesn’t make them bad from a health perspective. We need to respect that our bodies are dynamic systems. Changing the input will invariably change the output, and the system might need a few months to adapt to a new normal.

If your cycle goes wonky but you’re otherwise feeling good, give it a few months to sort itself out. If after a few months it’s still all over the place (or definitely if you’re having other disruptive symptoms), enlist help. In the meantime, check to make sure you’re not short-changing yourself nutritionally or calorically. Scale back on fasting efforts, and consider shifting more toward a traditional Primal way of eating.

At the end of the day, if you go keto and experience negative effects, stop. Keto is super hyped right now, but if your body is sending you clear signals that keto is not a good approach for you at this time, don’t do it. You can always try again later. It might be that your first attempt at keto didn’t work, but with a few adjustments and some experimentation over time you can find a version of keto that works for you.

Thanks for reading, everyone. Do you have comments, questions, or feedback? Let me know below.

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References:

Comninos AN, Jayasena CN, Dhillo WS. The relationship between gut and adipose hormones, and reproduction. Human Reproduction Update 2014; 20(2): 153–174.

Fontana R, Della Torre S. The Deep Correlation between Energy Metabolism and Reproduction: A View on the Effects of Nutrition for Women Fertility. Nutrients. 2016;8(2):87.

Klok MD, Jakobsdottir S, Drent ML. The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. Obesity Reviews 2007;8(1):21-34.

Meczekalski B, Katulski K, Czyzyk A, Podfigurna-Stopa A, Maciejewska-Jeske M. Functional hypothalamic amenorrhea and its influence on women’s health. J Endocrinol Invest. 2014;37(11):1049–1056.  

Tena-Sempere M. Roles of Ghrelin and Leptin in the Control of Reproductive Function. Neuroendocrinology 2007;86:229-241.

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