Low-Carb For Any Budget Patient Guide

• The prevalence of prediabetes and type 2 diabetes has increased dramatically over several decades in parallel with the increasing prevalence of obesity (which now is over 40% of adults, across all ages).
• Over half of Americans have prediabetes (hemoglobin A1c 5.7–6.4%) or type 2 diabetes (hemoglobin A1c ≥6.5% or on diabetes medication). These numbers have tripled since 1990.
• Obesity, prediabetes and type 2 diabetes are all risk factors for cardiovascular disease (CVD), and their increasing prevalence is now leading to an increase in the prevalence of CVD.

• A low-carb diet is powerful for improving Type 2 Diabetes, Metabolic Syndrome, High Blood Pressure, and Obesity.
• If done correctly, low-carb nutrition is healthy since it can improve blood pressure, blood sugar, and metabolism. Consult your physician before starting a low-carb diet to review whether medication changes are necessary.

• Start at the top of the hip bone, then bring the tape measure all the way around your body, level with the umbilicus. You can hold the beginning of the tape measure at the umbilicus and rotate 360° in front of you to accomplish this.
• Make the tape snug but not tight and record the measurement right after exhalation. Note: if waist circumference multiplied by two is greater than your height, then risk is higher for metabolic syndrome. Use the same unit of measurement for both (e.g., inches).

• You should be seated, relaxed, and rested for five minutes prior to measurement. Use an appropriately sized cuff since a cuff that is too small falsely elevates the reading. Note: Many individuals with diabetes have stiff arteries, which can cause a falsely elevated blood pressure reading.
• While not tracked at every visit, it’s also important to keep a log of the following:
  • Lipid panel, including: Total cholesterol, HDL, LDL, and triglycerides
  • Thyroid-stimulating hormone (TSH)
  • Hemoglobin A1c (HbA1c)
  • Vitamin D

Standard Glucometer versus Continuous Glucose Monitor (CGM)
Testing your blood glucose before and after meals as well as with exercise is essential to figure out how your body works. In the authors' opinion, there is nothing more powerful than seeing your own response to food and glucose curve and correspond to how you feel. The technology has become more accessible, affordable, and user friendly in the last year with the Freestyle Libre as an entry level CGM. Watch for reactive hypoglycemia.

Large post-meal spikes are a big issue with patients who have standard high carbohydrate dietary patterns, are insulin-resistant, and in later stage T2D with beta cell insufficiency. The CGM shows these patterns as well as a resolution of patterns with an individualized approach.

• Do you have obesity, diabetes or another metabolic problem (high blood pressure, fatty liver, PCOS, cardiovascular disease, sleep apnea)?
• Are you interested in losing belly fat, halting or reversing diabetes, and/or lowering your likelihood of cardiovascular diseases?

If you answered “YES” to any of the above, low-carb may be right for you!

• Do you have any acute, unstable medical conditions?
• Are you currently pregnant or breastfeeding?
• Are you taking any medication for diabetes or high blood pressure?

Carbohydrates

Note: "No Limit" does not mean "eat to excess". Enjoy these foods, eat slowly and mindfully, but you do not need to count servings or grams.

The effective carbohydrate intake level can vary considerably from person to person, as can strategies for determining that level.

The level depends on several factors including age, gender, metabolic rate, insulin sensitivity, activity level, and quality of carbohydrate (glycemic index/load).

One effective strategy is to start at a level that is effective for most everyone, typically less than 50 grams of total carbohydrate per day (less than 20 grams is more effective in many). This level achieves weight loss and dietary ketosis (safe) in most individuals. In coronavirus terms, this is a hard lockdown on sugar and processed carbs!

• As each individual reaches the goal for weight or another goal, such as blood glucose control.
• If cravings for carbohydrates might lead the individual to abandon the eating plan.
• If side effects of the eating pattern (e.g., fatigue or cravings) cannot be managed otherwise and threaten continued adherence.

Ideally, 5 grams of carbohydrate from one type of food (e.g., ½ cup berries, 1 cup of non-starchy vegetables or 1 oz of nuts) is added daily for 1 week.

• If weight loss (or weight stability, if that is the goal) continues, then another 5 grams of carbohydrate from the same or another type of food can be added.
• In this manner, the individual can identify a level of carbohydrate intake below which weight loss can be achieved and a higher level at which weight stability can be achieved.

A low-carbohydrate nutritional approach has a natural appetite reduction effect to ease you comfortably into the consumption of smaller and smaller quantities. Therefore, counting calories is not required.

• Eat when you are hungry and stop when you are comfortably full.
• You do not have to eat everything on your plate “just because it’s there.”
• You do not have to eat if you are not hungry. This usually happens spontaneously after a few weeks. Skipping meals is acceptable as long as you do not overeat or eat high carbohydrate foods later due to delayed hunger.

It is VERY important when following a low-carbohydrate nutrition therapy to adjust medications to minimize the risk for hypoglycemia and hypotension. Consult with your physician. Checking your blood glucose and blood pressure at home is essential.

• Reducing carbohydrate intake potently reduces blood glucose level, which means that diabetes medications can be reduced or even stopped in some cases.
• Reducing carbohydrate intake also leads to water loss. As a result, blood pressure can decrease and dehydration can occur if water and sodium are not replenished, especially if you are taking a diuretic.

Insulin should be adjusted down and sulfonylureas (i.e., glipizide/glyburide) should be stopped ON THE SAME DAY that you are starting the new eating plan.

As weight loss continues, blood glucose levels will decline and further medication reductions may be necessary.

As you improve your insulin resistance, medications which can lower blood glucose will likely need to be reduced or eliminated. Check your blood sugar regularly! Blood pressure can improve also, so monitor with a home cuff and consult with your doctor.

• Diabetes medications—insulin and sulfonylureas: Doses should be REDUCED or STOPPED BEFORE starting a low-carb diet to prevent hypoglycemia (low blood sugar).
• Metformin: Can be used in a low-carb diet.
• Blood pressure medications: A low-carb diet can improve blood pressure. If you have a pressure below 110 mmHg, headache, or feel lightheaded, your blood pressure medications may need to be changed. Diuretics especially should be reduced.
• Blood thinners: Coumadin (warfarin) should be monitored more frequently when transitioning to a low-carb diet, especially if vegetable-intake changes.

• Myth: Low-carb nutritional approaches are a fad.
  Response: Over the past several decades, many randomized controlled trials, both short term and long term (up to 2 years or more), have demonstrated that a low-carbohydrate eating pattern is effective for weight loss, metabolic improvement, and weight maintenance.
• Myth: Low-carb is bad for your heart.
  Response: Carefully controlled randomized trials have demonstrated reduction in cardiometabolic risk factors and carotid intimal thickness.
• Myth: Low-carb is not sustainable long-term.
  Response: Reducing daily carbohydrate intake has the effect of decreasing appetite and increasing satiation or sense of fullness and corresponding biomarkers. This effect assists in long term maintenance. Randomized trials typically show that patients persist with low-carbohydrate eating plans similarly to comparison diets.
• Myth: Ketosis is dangerous.
  Response: Restricting dietary carbohydrates has been an established treatment option for children with hard-to-control epilepsy since the 1920s and has no proven deleterious effect on cognitive function or health.
• Myth: Plant foods are reduced on a low-carb program.
  Response: Non-starchy vegetables (green leafy, cruciferous, zucchini, cucumber, celery, etc.) are the foundational foods of a low-carbohydrate eating pattern and are nutrient dense with abundant amounts of folate, potassium, vitamins, and phytonutrients. Proteins or fats can also be obtained from vegetable sources such as nuts, tofu, tempeh, olive oil, avocado, and others.
• Myth: Ketone products and extra fats are necessary to get into nutritional ketosis.
  Response: The most important factor to attain nutritional ketosis is to consume a small amount of carbohydrate. Adding ketones or fats or oils is not necessary.
• Myth: Low-carb eating patterns negatively influence kidney function.
  Response: This myth stems from the confusion between low-carb eating patterns and high-protein eating patterns. Low-carb does not necessarily mean high protein. Further, for people without existing kidney disease, and for those eating to satiety, higher protein intake does not appear to be related to lower kidney function.

How Low is Low-carb?

• “Low-carb diets” can refer to a range of carbohydrate intake from less than 130 grams a day to a very low-carb or ketogenic diet where the goal is 20-35 grams of non-fiber carbohydrates per day. The goals are to reduce carbohydrate intake, which reduces your body's insulin requirement and, in ketogenic diets, to produce ketone bodies for fuel.

What is Ketosis?

• Glucose (from sugar or other carbohydrates) is the most common fuel source for the body. Ketones are produced by the liver as an alternate fuel source when glucose is not available. Ketosis is the presence of ketones in the blood. Most people develop low levels of ketosis after an overnight fast or carbohydrate restriction. This low-level dietary ketosis is not harmful and can be therapeutic. Ketone levels induced by a low-carb diet will never approach the levels induced by frank insulin deficiency as in diabetic ketoacidosis. The breath of people in ketosis can be described as “fruity.”

How Will This Affect My Lipid Panel?

• A low-carb diet has higher dietary fat but has positive effects on the lipid panel. HDL (good cholesterol) can increase, and triglycerides usually decrease. LDL and total cholesterol usually remain stable, especially after the new weight is maintained. Cholesterol can go up during weight loss. In almost all cases this is fine. Discuss with your doctor.

What Else Can Help?

• A low-carb diet is part of a multifaceted lifestyle change. Adequate sleep, physical activity, reduced stress, learning to cook, support from friends and family all will help you restore your health.

Are There Any Side Effects?

• There are a few possible side effects, and most are minor and easily managed. See Table 2 on the following page to review the most common ones, and how to resolve them.

1. Buy meat and fish from the counters at supermarkets, it's usually less expensive than straight from the fridges. If you can, go to your local butcher and fish shop since they can be even cheaper.
2. Buy loose fruit and vegetables, it's usually less expensive than prepackaged fruit and vegetables, but sometimes frozen vegetables can be cheaper. Also, buy less popular fruits and vegetables or go direct to your local greengrocer or farm shop since both alternatives can offer an even better price.
3. Cook in bulk with dishes, then store in containers for freezing and heating up quickly the next time.
4. Before going shopping, compare foods online for the best prices and account for any coupons that might be available.
5. Don't go shopping on an empty stomach!

When you begin eating low-carb, the first and biggest obstacle can be, “What do I eat?” Use these handy shopping lists to help guide you through the grocery aisles. Green List Foods are nutrient dense, low in carbs, and satisfying.

Foods on the Yellow List offer multiple health benefits but may hinder your weight loss journey if consumed without restriction. Thus, foods on this list are meant to be enjoyed in moderation.

You should hardly ever consume foods on this list.

Foods to avoid and not have in the home!

• Was the food once alive?
• What are the ingredients?
• Are the ingredients nutritious?
• Where did the ingredients come from?

Hint: Did your food come from something living or was it made in a plant? Buying locally-sourced food is always best.

( cookingketowithkristie.com/getting-started-2/ )

1. Count All the Carbs and Keep Them Low.
   • When I first started low-carb, I didn't know a macro from a micro, but I knew that I had to count carbs. Count total carbs; do not subtract fiber. That's all I knew for the first few months, and I lost over 40 lbs. in that time. I discontinued all of my medications in those first four months. This doesn't have to be complicated. Despite all the detailed information here, don't wait for perfection. Don't drive yourself insane counting macros, weighing, and measuring. For accurate carb counts, use the online USDA database to find nutritional values (ndb.nal.usda. gov/). If the food you're eating has a label, then use the nutritional information on the label. Know the carb count of EVERY food you put in your mouth BEFORE you put it in your mouth.
2. Commit.
   • Decide you're going to follow a low-carb plan 100% for two weeks. I promised myself that at the end of my two weeks, I'd eat the entire doughnut shop if I wanted. Just two short weeks. I was desperate, and I knew I had to follow the plan 100%. Even one little Hershey's Kiss can throw your body off, and you will not see the results you want. Low-carb can be unforgiving for those of us with metabolic dysfunction. Moreover, during those two weeks, you will be able to push through cravings and enjoy the benefits. Once you accomplish two weeks of success, the plan gets easier. Commit to four short weeks; one day at a time. No sugar, no starch, no grains. Decide "Come heck or high water, I'm following this plan for four solid weeks." Then do it.
3. Find Your Favorite Low-carb Foods to Eat
   • Use the food lists, sample meal plans, and the recipes in this book to find your new favorite foods. My favorites are steak, chicken wings, creamed spinach, and homemade Ranch salad dressing. When I'm tired of that, I've got meatloaf, taco soup, pepper steak, and coffee with heavy cream. As you identify your new low-carb foods, pick mostly from the green and yellow lists in the Getting Started Guide because those are the foods with higher fat and lower carbohydrates. You can eat from the Red List occasionally, but you may surpass your carb limit more quickly than you intend.
4. Limit Carbs to 7–10 Grams Total Per Meal
   • The "magic" that makes a low-carb plan work is linked primarily to keeping blood glucose stable. Eating higher carb meals will raise blood glucose, which is why you have to be 100% on-plan and remain vigilant about counting carbohydrates. The physicians I follow who recommend a low-carb diet generally advise patients to count total carbs, which means not subtracting fiber. Some soluble fiber may impact blood glucose, especially in packaged foods. Therefore, counting total carbs is a more conservative, but safer, guideline. While you may find that you can tolerate up to 12–15 grams of carbs per meal, many people cannot. Cravings are worse for me when I exceed 7 grams of total carbs per meal. Through trial and error or blood glucose monitoring, you can find your carb threshold.
5. Eat to Hunger
   • A low-carb diet does not work by starving the body. Low-carb works by eating high fat foods with adequate protein such as fatty meats, bacon, chicken with crispy skin, etc., that keep blood glucose stable. Eat when hungry. Don't gorge, but when your hunger is satisfied, stop eating. Moreover, do not eat again until you are physically hungry. As I explained to my husband, "If you're hungry, you're doing it wrong." Don't worry about how many strips of bacon make a serving. There are days when I am physically hungry: eight pieces of bacon and three eggs are not "too much" on those days. On other days, two pieces of bacon and coffee are sufficient. Fat tends to be self-limiting and can make you sick if you overeat it. You will learn quickly when you've overeaten fat.
6. Learn to Listen to Your Body
   • Know whether you're eating what's "right" by listening to your body. An ideal low-carb meal meets these requirements:
     • A. You leave the table feeling satisfied. Not stuffed, but comfortable.
     • B. You don't feel tired or sluggish 1–2 hours after eating, but you do feel energized. If you do feel tired or sluggish, then your meal was not ideal. Feeling tired and sluggish can be linked to eating too much protein, too many carbs, or a food sensitivity. Make note of the grams of carbs, fat, and protein in your meal. Use the USDA database or the nutritional label for accurate macros.
     • C. You do not feel hunger (true physical hunger) for at least 4–6 hours after the meal. It takes a body that long to metabolize a meal when the balance of macros is right.
7. Learn Your Hunger Cues
   • Physical hunger is not feeling anxious, frustrated, angry, or happy. Hunger is not an emotion. True hunger is not triggered by a commercial on television or by someone around you eating. Physical hunger is disruptive. It stops you from what you're doing, and says softly, "Uhm... I need a little fuel here." If you're busy and you get distracted by hunger, you're truly hungry. When you're hungry, eat. If you're not physically hungry, drink water, phone a friend, run an errand, clean, or go for a walk. Learning to trust physical hunger cues is a significant key to success.
8. Don't Try to Take Shortcuts
   • There is no substitute for real food. Whether you're tempted by convenience of "low carb" products (that are not really low in total carbs), or tempted by supplements that promise ketosis, or simply toying with the idea of a three-day gimmicky "diet," "detox," or "fast," then don't. Learning to eat nutritious foods and changing your habits for the rest of your life is going to make you healthy in two weeks, two months, two years, and two decades. Looking for shortcuts never moved me further along on my journey for any length of time.
9. Eat Real Foods and Pay Attention to Ingredients
   • Looking for convenience, I made this mistake. If a food is marked "low-carb," "sugar-free," or even "keto," it probably isn't a good option. When you pay attention to ingredients, you find that many sweeteners used by food products will impede your progress. For example, diet soft drinks can cause stalls, and many people find that drinking them increases hunger. Those who pay attention to ingredients are more likely to see better results.
10. Create New Habits
    • You will not succeed by doing the same things you've always done. To be successful, you will have to think differently about food and meals. When you eat, what you eat, and why you eat are going to be different on a low-carb plan. You will have to learn to eat different foods, and create new meals. For breakfast, I often eat non-traditional breakfast foods, such as a burger with cheese and bacon, smoked sausage, bacon with cream cheese, or a skillet pizza. For quick lunches, I often eat leftovers or salad with deli meat, a boiled egg, cheese, and lots of homemade Ranch dressing. A juicy cheeseburger with bacon and mayo (hold the bun) is always delicious and easy to find on the go. Even if you don't like to cook, you can still create low carb meals that you enjoy. If you don't DO something different, you will never BE different.

• Drink according to thirst. Beverages that you can drink while following a low-carb diet include water, tea with no sugar added, and coffee. Tip: make your water more tasteful by adding cucumber slices, lemon pieces, mint, or ginger parts.
• Cook extra for leftover day! Meals that have more than one portion can be enjoyed on other days.
• If you remain hungry, then add more fat and protein to your cooking (i.e., additional cream/butter/meat/fish/egg) to help you feel full. You may also eat more vegetables.
• Try not to eat snacks in between meals. But if you feel the need, then choose hard cheese or salami, snack on a handful of nuts, or a hard-boiled egg.
• Stop eating when full and eat only when hungry. You are welcome to skip meals if you don't feel hungry and to eat larger portions at other meals if you are hungrier. Save any leftovers for your next meal.
• Drink your food and chew your drink (this means chew and enjoy the foods, and drink slowly).
• The portions given in the recipes are just guidelines. Everyone is different and may need more or less to feel full.
• Prepare low-carb meals in advance. That way, you will not be tempted to buy any snacks/meals that are not low-carb friendly.

1. Record your BMI (a simple calculation you can do with weight and height).
2. Know the difference between being hungry and being thirsty.
3. It takes about 5 weeks to break a habit and about 5 weeks to form a habit.
4. Measurements are important because you may lose inches and not weight at times.
5. Non-Scale Victories (NSV) are important. Good for moral support.
6. Don’t let the scale get in your head. Don’t worry too much about the scale. Follow the program for maximum benefit.
7. MYTH: You cannot do low-carb without a gallbladder. I have heard this from hundreds of people and have been asked lots of times. FACT: You can. You may need an ox bile supplement at first, but not always.
8. Exercise is not a must initially; however, once you start losing weight and/or regaining your health, you will feel more like doing activities you did before (exercising, hiking, roller-skating, etc.).
9. Pickle juice and mustard are good for muscle cramps.
10. Magnesium is good for constipation.
11. Keto flu for beginner: use bouillon twice a day or a pinch of salt.
12. Community is important. Reach out to a local low-carb group on social media.
13. Be cautious about portion size on trigger foods, such as nuts.

Cooking interesting versus cooking average is all about what you have in the fridge and freezer with a few pantry staples. This is your toolbox for adding variety, flavor, and fun. There are lots of low-carb options at reasonable prices.

Here is an example of one shopping trip as well as some staples (spices, oils, and flavors). This basic list can be applied at almost any discount grocer and even at dollar stores. Starting on the opposing page, you'll find a list of simple recipes and meals that can be created with these ingredients.

That sweet tooth doesn't just go away because you've gone low carb. Most often you can fight cravings with high fat options like bacon or pork rinds dipped in softened butter. But for those times when only a sweet treat will do, you still have options.

• The real trick to making low carb treats that you can enjoy is finding a sweetener that you like. Whether it's stevia, erythritol, monkfruit, or something else, it can often take trial and error to find something you like. Be sure to add only small amounts of sweetener at a time and use the guide on the packages to see what might be the best amount to add.
• One easy way to taste test sweeteners is to add coffee or tea before using the sweetener in a recipe. That will give you an idea of how sweet the product is when compared to real sugar.
• Another important consideration for making treats is to keep them as an option for truly special occasions, so that they aren't consumed frequently. One tip that many find helpful is to make small treats so that portion control is easier.
• A second option is to freeze portions so that treats are available, but not immediately so. Having an option on hand in the freezer is especially helpful for cravings, but keeps those items out of sight to avoid mindless eating.

CAUTION

Low-carb desserts are not low calorie. May stall weight loss.

Bright Spots are positive behaviors and choices you want to replicate as often as possible. They are the things that you're doing right that you should try to duplicate.

Landmines are the mistakes you make over and over again that drive your blood glucose out of range, ruin your mood, or make life more difficult; you want to find ways to stumble on landmines less often.

Good luck on your journey!

CHOOSE LIFESTYLE MEDICINE VERSUS A LIFETIME OF MEDICINE.

We thank and acknowledge the hundreds of incredible clinicians, research scientists, investigative journalists, farmers, chefs, health advocates, and most importantly, the millions of individuals and patients who are changing the world and giving hope. We have learned so much and continue to learn from you.