June 26 2017

Dear Mark: Ketosis and HIIT, Keto After Menopause, Inuit and Ketosis?

By Mark Sisson
30 Comments

Inline_DM_06.26.17For today’s edition of Dear Mark, I’m answering a few questions from you folks. First, can a person maintain their high intensity interval training while starting a ketogenic diet? Is there anything you should watch out for? Second, is keto a good option for postmenopausal women? Though we don’t have any direct research on the subject, there is hope. And then we discuss the peculiar case of the Inuit and the missing ketones.

Let’s go:

First, Matt B asked:

I’d also like to know if HIIT workouts can be properly fueled during ketosis. My swimming coach is convinced that ketogenic diets are terrible for HIIT workouts and therefore advises against ketosis entirely.

As I said in last week’s post on keto caveats and contraindications, starting a ketogenic diet while in the midst of a season or when you’re about to start one probably isn’t advisable.

Here’s what you can do:

Once the season ends, go keto for at least six weeks. Try to stay in full-blown ketosis—low carbs, high fat, moderate protein—for those six weeks. Maintain your normal training schedule and realize that your performance will suffer for the first 3-4 weeks.

After those six weeks, incorporate carbs before or after intense training efforts. Note their effects. Do the carbs help your performance? Keep eating them, making sure to time them with your workouts. Do the carbs have no effect? You may not need them after all.

The season is a different story. You’ll probably need some carbs around your workouts and meets. If you still want to remain in ketosis, don’t worry too much; as long as you use the carbs you eat, they’ll go toward refilling your muscle glycogen stores without impacting your ketogenic status too much.

Luckily, the benefits of full blown ketone adaptation don’t just disappear. Your muscles will still be good at burning fatty acids and ketones. You’ll still have higher mitochondria density to produce more energy. And as long as you revisit ketosis on occasion, you should maintain most of the metabolic benefits.

Regarding keto, Louise asked:

Would you recommend it for perimenopausal/menopausal women?

That’s tough to answer based on the literature. There aren’t any dedicated ketogenic diet studies on post-menopausal women. Though what we have on low-carb diets, which are often ketogenic by accident, is quite positive.

For instance, post menopausal women on a low-carb, high-fat cheese-and-meat-based diet fared better than women on a low-fat, high-carb diet. Their blood lipids improved, including lower LDL particle numbers and higher HDL. There’s no word as to whether this was a ketogenic diet, but I wouldn’t be surprised if they attained ketosis.

In another, post-menopausal breast cancer survivors were randomized to either a low-fat diet or a low-carb diet. Although average weight loss was similar in both groups, more individuals on the low-carb arm lost a greater percentage of their body weight.

A full-blown paleolithic diet is also quite good for post-menopausal women. In one study, going paleo helped post-menopausal women lose more body fat, more abdominal body fat, more inches on the waist, and achieve lower triglycerides.

As many of my commenters noted in the original post, the scientific community at large just doesn’t like to focus on post-menopausal women. Maybe it’s that the questions are too complex (hormones are complicated, especially when they change so rapidly). Maybe there’s not as much money behind it (youth sells—and I say this as someone in his 60s). Whatever the reason, it’s not right. Hopefully, we get more research coming down the pike. I think I’ll do a post on gender disparities in research, come to think of it. Stay tuned for that.

Still, I see no reason why a ketogenic diet wouldn’t help post-menopausal women.

My general advice for everyone stands: Try it out for a few weeks, see how you feel, and be honest with yourself. Don’t feel beholden to any dietary “regimen” or “ideology” (except, perhaps, “eat real food”) if it doesn’t work for you. Sure, quality matters. You can do a ketogenic diet wrong, so make sure you do it right. Don’t do a soybean oil/Splenda/cream cheese keto diet and complain about keto when it doesn’t work, but don’t do something even if it’s clearly not working for you just because someone you trust recommended it.

Melanie asked:

I would be interested to hear more – can you expand? What kind of mutation do the Inuit have and how does this prevent ketosis? Thanks you, Claudio!

The Inuit are an interesting bunch with regards to ketosis. Despite eating almost nothing but seafood and marine and land mammals and their fat, with negligible amounts of carbohydrates, the Inuit rarely show evidence of ketosis. A legitimate fast isn’t even enough to reliably produce ketosis in the Inuit. It turns out that many of them possess a gene variant that prevents ketosis and drops blood sugar during fasting and starvation.

Similar variants in other groups are considered deleterious. It can be fatal to infants and children without instant treatment. It’s rare in most populations, probably because it’s historically been such a knock on reproductive fitness. You want your toddler to be able to survive a day without food, after all.

Yet in the Inuit and other Arctic populations, these mutations are incredibly common. What’s going on here? Why was it preserved in the Inuit, let alone selected for?

First of all, the gene variant doesn’t seem to be deleterious in adult Inuit. A number of studies have shown that Inuit with the mutation tend to have less body fat and better blood lipids, though the mutation is still dangerous in kids and babies.

The mutation also makes it easier for carriers to burn free fatty acids in mitochondria. This is a good thing for a population like the Inuit on a traditional diet, because they’re swimming in free fatty acids and they aren’t able to produce ketones or eat enough carbohydrates for energy. Free fatty acids are everywhere. If you can use them more efficiently, you’ve got a great, reliable source of energy on demand.

Without a mutation like this one, the Inuit would likely be in permanent, deep ketosis. That can be hugely therapeutic in the right context. Ketones can prevent and treat epilepsy, for example. But what if there is a problem with long-term ketosis? Given the high-fat nature of their diet, this mutation is the only thing standing between a traditionally-eating Inuit and chronic, unavoidable ketosis. The rise of this mutation may have been a way to stave off that possibility.

In a roundabout way, ketone adaptation is a way for anyone not carrying the anti-ketotic genetic marker common among Inuit to obtain Inuit-type metabolism. Long term ketone adaptation leads to an increased ability of skeletal muscle to directly oxidize free fatty acids for energy; the Inuit with the mutation do that already.

That’s it for me. Thanks for reading, everyone. Be sure to help out below with your take on the questions and any advice you have for the people who asked them.

Have a great rest of the week!

TAGS:  dear mark, Keto

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30 thoughts on “Dear Mark: Ketosis and HIIT, Keto After Menopause, Inuit and Ketosis?”

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  1. More than an article about gender differences in research, we desperately need an article focused on postmenopausal women. Please!

    1. I agree. I did try keto based upon information from Maria Emmerich, whom I admire, but I found that I was hungry all the time. At 69 I found that Whole30 has worked best for me.

  2. In addition to a post on gender bias in research, it would be effective if you added “in men” or “in women” or “in men and women” every single time you mention a study. Given that a great many of the studies you link to involve only male participants, that would reveal the gender disparities pretty darn quick.

  3. “hormones are complicated, especially when they change so rapidly”, except when we’re post-menopausal, the hormone changes are over…

  4. Thank you for including the question about perimenopause/menopause, and for your honest answer! I’ve been curious about this myself as a mid-40s woman, and also about intermittent fasting for women dealing with hormone balance issues.

  5. Hmmm, what would be a good method of treating an Inuit child that has epilepsy? Very interesting.

  6. My advice to all the women with questions would be to try it and listen to your body. You can read about all the studies in the world, but they don’t always pertain to real life or to you as an individual. Yes, it would be nice if more studies had women as subjects. In the meantime, be your own study. I feel amazing eating high fat/low carb most of the time. If I stop feeling amazing, I’ll tweak it, or try something else. No idea if I am in actually in ketosis., but I probably am some of the time. I just know that I am able to maintain a busy schedule and have a ridiculous amount of energy. But if I want some carbs, I have them. Especially if chocolate is involved:)

  7. My wife tried keto for an entire month. Didn’t lose an ounce of weight. Tried paleo too. Same results.
    *sigh*

    1. Keto is the best weight-loss diet out there but it may not work for everyone. It might be worth your wife’s time to keep a daily journal of everything she eats. Often “errors” in one’s eating pattern will become obvious after a week or so. Also, invest in some keto sticks, cheap at the drugstore. She might think she’s in ketosis but really isn’t. The sticks can be a good indicator. Lastly, it might take more than a month to see positive results so she should hang in there. A Paleo coach might be able to help, or an MD that specializes in weight loss.

    2. Your wife and I are in the same boat. The Whole30 worked better for me than anything I’ve tried previously.

  8. Mark, thanks for your thoughts on the Inuit. You linked to a very interesting article. With the state of the current science on this mutation, it is unclear whether it conferred a metabolic advantage, but certainly possible. It may be related to infection sensitivity, as many deleterious-seeming SNPs, such as the one causing sickle cell anemia. Either way, in my opinion it is too early to say whether the mutation occurs with high frequency in Inuit to prevent long-term ketosis.
    To quote: “The extent to which the c.1436C>T mutation contributes to disorders associated with CPT1 deficiency, such as hypoketotic hypoglycemia and sudden infant death syndrome, is still unclear. The derived allele has been reported as being deleterious in both the homozygous and the heterozygous state. Yet, its phenotypic effect might depend upon many environmental factors, e.g., feeding history, infection, and climate.13, 27 It is known that the mutation decreases fatty-acid oxidation and ketogenesis, explaining its role in hypoketotic hypoglycemia.13, 28 However, there is also evidence that the mutation decreases the inhibitory effect of malonyl-CoA on fatty-acid ?-oxidation in mitochondria, thereby partially compensating for the drop in ketogenesis associated with reduced CPT1A activity.13, 28 A study on Alaskan Yup’iks also suggests that the c.1436C>T mutation might exert a cardioprotective role through its association with elevated levels of high-density lipoprotein cholesterol and reduced adiposity.28 Moreover, the large amounts of n-3 polyenoic fatty acids in the traditional diet of these aboriginal peoples are known to increase the activity of CPT1A.13, 28 In this context, the CPT1A-activity decrease due to the c.1436C>T mutation could be protective against overproduction of ketone bodies.13 These important metabolic effects of CPT1A provide the basis of our hypothesis that the c.1436C>T mutation might have conferred a metabolic advantage for the Northeast Siberian populations in dealing with their traditional high-fat diet. The deleterious effect of the mutation might be explained by a change from the traditional diet to a more carbohydrate-based one or by recent cultural shifts and environmental stressors such as fasting and pathogens.”
    Thank you!

  9. Sixty-something female here. Been Primal Blueprint, low carb moderate fat for a number of years–all strictly real food. Almost all my carbs are from non-starchy vegetables. Gave keto a go but feel it is probably not for me. Keto flu persisted as did hunger and I got tired of it! I also question the wisdom of so much fat.

    I am formerly morbidly obese which may have something to do with my experience. For now going back to my regular Primal diet which I love, but won’t rule out trying keto again in future. If nothing else my trial run has helped me cut down on daily carb intake again as I go forward, even if it is all non-starchy veg! So it was worth doing.

  10. Forgot to say I am anxious to read Mark’s new keto book as soon as it comes out!

  11. Mark, the training question prompted a related question: is it a problem to hover on the edge, coming in and out of ketosis–I mean, it’s what I think of as basic Primal eating, with carbs typically low, but an occasional amount that may take you out of ketosis…I’m not clear on the advantage of extending the ketotic state longer (since I’m not using it therapeutically, as in epilepsy). Do you need to “stay pure” for a while to really see benefits?

    1. I’m really interested in this too. Most keto info seems to come from keto zealots who don’t consider that an otherwise healthy person might not want to be keto all the time, but I see a lot of reports of people who’s metabolic markers go in a worse direction if they move toward keto but don’t permanently stay there.

      More generally, thanks , Mark, for taking on these topics. The world certainly does not need another “Keto is perfect” book so a more pragmatic view and a “Keto for otherwise healthy people” view is sorely needed.

  12. Hello.
    I am post menopausal. I have been paleo for one and a half years, in and out of ketosis. I have never felt better. I figured I would do everything in my power to decrease inflammation. I sleep great. The fat/cellulite on my body has melted off, though not much weight loss. I am seriously happy and pleased. It did not alleviate hot flashes (darn!). I wanted to take away any variables when managing hormones, I cant think of a smarter thing to do. I work with the brain for a living. Gotta walk the walk. And I will be in any study!!!!
    Just sayin…….

  13. Thanks Mark! Wish I had this source of information years ago! Now, I intuitively listen to my body and have gotten to a place where I know what my body is telling me. Sometimes it’s high fat and other times I need to up the carbs 😉 Appreciate all you do Mark!

  14. Thanks for the article Mark. I’ve been on a keto eating plan for the last 2 months. Although not overweight, menopause had put an extra layer of fat around my waist that was impossible to lose, until I tried keto. I’m happy to say that I’ve lost all of my waist fat, don’t have any cravings for sugar nor carbs (starchy ones) and I don’t have any desire to go back. My ratios is typically 70% fat, 20% protein and 10% carbs from vegetables. As for workouts, I do HIIT 2x per week and the rest of the time I go for easy walks around the neighborhood. I love this new way of eating.

  15. I’ve been following a keto diet for over 10 years and recently cruised through menopause with no problem. I believe stable blood sugar is the answer to many modern day health issues. I am stronger and have more energy now than when I was in my 30’s.

  16. Hey! Wait a minute. If animals don’t go into ketosis, and inuits don’t go into ketosis, maybe they’re not the ones with the mutation. Maybe carbohydrate adaptation was just not selected for in Inuit areas. Do other animals have mitochondria like the Inuit?

  17. Mark says: “Without a mutation like this one, the Inuit would likely be in permanent, deep ketosis…Given the high-fat nature of their diet, this mutation is the only thing standing between a traditionally-eating Inuit and chronic, unavoidable ketosis.”

    Unfortunately, that’s false. While nobody would dispute that their traditional diet is high in fat, the Inuit diet has *never* been shown to have the proper ratios to support ketosis. Not one single paper observing actual Eskimos has ever shown them to eat a ketogenic diet, while over a dozen scientific papers and observations document their diet as having too much protein to be ketogenic.

    The following scientific papers and observations all showed high protein diet (all publicly accessible):

    • Krogh & Krogh 1914 (Nobel Prize winner)
    • Lusk 1914
    • Joslin 1917 (first doctor to ever specialize in diabetes in the US)
    • Schaffer 1921
    • Heinbecker 1928, 1931, 1932
    • Tolstoi 1929
    • McClellan & DuBois 1930 (Stefansson’s own doctors)
    • Rabinowitch 1936
    • Rabinowitch & Corcoran 1936
    • Rabinowitch & Smith 1936
    • Kaare Rodahl 1952
    • Sinclair 1953 (A detailed review of the literature)
    • Ho 1972
    • Hui 1975
    • Bang, Dyerberg & Hjorne 1976
    • Draper 1977
    • Bang, Dyerberg & Sinclair 1980
    • VanItallie & Nufert 2003
    • Leonard & Snodgrass 2005
    • Hardy 2005

    In fact, the only scientific papers claiming that Eskimos ate a ketogenic diet were those who used white explorers’ diets (such as Stefansson’s) as a proxy for Eskimo diets (an exercise in circular reasoning). Steve Phinney made such an argument, using circular reasoning.

    Furthermore, the late Per Wikholm meticulously documented, (for Sweden’s “LCHF Magazinet”) using Stefansson’s own writing, that Eskimos were not eating ketogenic ratios. Stefansson struggled to eat the amount of protein that Eskimos did. In fact, this is why Stefansson failed in the beginning of the Bellevue Experiment—he was unable to consume the Eskimo diet that had been documented by Krogh & Krogh and this was noted in their report.

    Mark, I do believe you owe it to your readers to be honest with them. The traditional Eskimo diet has *never* been shown to be ketogenic and there are *zero* scientific observations of traditional Eskimo diets that show anything approaching ketogenic ratios. Sinclair’s 1953 review even stated that the amount of fat consumed by Eskimos would have to be “doubled” to be ketogenic.

    I would also add that CPT1a allows Eskimos to direct FFAs away from their livers and shunt them to muscles and brown fat (for thermogenesis). This is said to be why Eskimos were warm to the touch—they made their own heat.

    Finally, Eskimos could not afford to gorge on fat all day. First of all, many of their animals tended to be lean and they had to save their fat for fuel (and trading with inland tribes), to survive the long dark winters.

    Cheers,
    Duck

  18. I am post menopausal. I have been primal for 4 years and decided to shift to a KETO diet with a goal of losing stubborn fat from my midsection that decided to “take up residence” after I turned 50. Typically, I consume 70-75% fat, 20-25% protein and 5-10% carbohydrate from vegetable sources. To date, I’ve lost all of the fat off of my midsection and now I’m seeing fat loss in my arms and legs. As for enjoyment of the new eating plan…I find it very easy and super satiating.

    I don’t know if we are going to see any research on post meno and KETO, but I can tell you, through my experience, I am loving the results in my body composition and my energy levels.

  19. Ok but what if we aren’t an athlete, but just a regular person who actually likes going to gym classes like Zumba , boot camp , cycling and we like HIIT , but we want to live a Keto lifestyle. Is that possible ? What do we have to do to keep doing the high cardio things we love and also be keto?

  20. 53 year old mama of 16 here, menopause came on like a never-ending train wreck. The hot flashes were ruining my sleep, and in the grocery store one day, I almost took off all my clothes. So I tried keto, back when keto wasn’t cool. The hotflashes STOPPED. My creeping blood pressure went down nicely, and my A1C was perfect after a few months. I was still heavy, still am, a work in progress, but for me, keto was the answer to those pesky menopausal discomforts.

    Della