Case report: Denis, and how the ketogenic diet saved his life
Denis had a very normal childhood with a modest Québécois upbringing. As a child, he was considered “plump,” but as a teenager he became very sport-centric. He took advantage of school equipment and performed a lot of physical activity.
Adulthood brought a lot of demands and stress. With the birth of his three daughters, his sports activities decreased, and a slow weight gain commenced, interspersed with all sorts of different weight-loss diets, each as disappointing as the last. He always experienced weight loss consistent with his goals, but would frustratingly regain the weight he’d lost. He kept growing bigger even though he had spent half his life depriving himself. Denis was so frustrated with dieting he vowed never to do it again.
His general energy had always been good. Even when he went back to school, and during promotions and moves, he was never without projects. However, a great whirlwind in his life caused him to go through an extremely difficult time, which ended in bankruptcy.
This is when his health began to noticeably deteriorate. First, with the diagnosis of high blood pressure, and then type 2 diabetes.
Denis rigorously followed all the prescribed medical treatments. Despite this, his list of medications kept getting longer. He was on ten drugs. He lost hope of curing or even simply limiting his diabetes complications.
His doctor at the time explained to him that his treatments would cause him to continue to gain more and more weight. He was frustrated that he would never recover from this disease.
Denis’ wife then discovered the ketogenic diet, thanks to her wonderful French friends. Her energy and health quickly improved. When her friends — avid followers of the ketogenic diet — came for a visit, Denis was intrigued.
Curious but still a bit confused, Denis began reading Dr. Jason Fung’s book The Obesity Code and then The Diabetes Code. He began to realize many things, including how he’d gotten to his present state of health. Once he understood the disease, he was able to make peace with himself and his body.
Month one: the journey begins
Denis joined Clinique Reversa on October 12, 2018, and he declared that his main objective was to lose weight. He didn’t mention reversing his diabetes, probably because he didn’t believe that it could indeed be reversed. He weighed 271 pounds (123 kg) and his blood pressure was 182/72 on that day.
He was taking long-acting insulin, 216 units, amlodipine 5 mg twice a day, aspirin 80 mg, atorvastatin 40 mg, lisinopril-HCT 12.5 mg – 20 mg, metformin 850 twice a day, gliclazide 80 mg twice a day, dapagliflozin 10 mg, and saxagliptin 5 mg.
As I do with all diabetic patients on a SGLT2 inhibitor who want to start a low-carbohydrate diet for their type 2 diabetes, I immediately deprescribed his dapagliflozin. This class of drug increases the risk of diabetic ketoacidosis in patients on a low-carb or ketogenic diet. It also works by forcing the kidneys to excrete sugar. Since my patients will practically not eat sugar anymore, I consider that they don’t need a fancy and expensive pill to urinate it.
I don’t reduce the insulin dosage that my patients are taking right away, unlike many other low-carb healthcare practitioners, unless their blood sugar levels are nearly perfect when they start at our clinic. Because we work as a multidisciplinary team, patients are instructed to email their blood sugar levels daily to my nurse or assistant if they do not have access to a continuous blood monitoring (CGM) device. We keep a close eye on them until the insulin is weaned off. We can react quickly and adjust their medication on a daily basis.
Many clinicians reduce the total number of units of insulin by one third to two thirds right away, but I prefer to adjust daily if necessary. It doesn’t take much time, and I do not want my patients to get discouraged by high blood sugar levels.
When reducing insulin dosage, we aim for blood sugar levels to be between 8 mmol/L (144 mg/dL) and 12 mmol/L (216 mg/dL). Anything above 12 mmol/L (216 mg/dL) requires a sliding scale of short-acting insulin, and anything below 8 mmol/L (144 mg/dL) means that it’s time to cut down the insulin some more.
I like to work on the long-acting insulin first, but in this case, it was the only type of insulin he was taking, so it was pretty straightforward.
On October 16, his insulin dosage was down to 196 units, which was already a very good start. I expected things to slow down with this patient. Boy, was I wrong!
Four days later, his blood sugar levels were:
- fasting: 5.2 mmol/L (94 mg/dL)
- afternoon: 3.4 mmol/L (61 mg/dL)
- supper: 2.7 mmol/L (49 mg/dL)
- after supper: 3.3 mmol/L, (59 mg/dL)
- evening: 2.9 mmol/L (52 mg/dL), then 2.5 mmol/L (45 mg/dL), then 2.7 mmol/L (49 mg/dL)
- bedtime: 4.5 mmol/L (81 mg/dL)
His blood ketone level was 0.7 mmol/L.
The next day he woke up with a 2.9 mmol/L (52 mg/dL), not feeling well at all.
I cut his insulin by 50%.
His following blood sugar levels were 5.8 mmol/L (105 mg/dL) and 5.5 mmol/L (99 mg/dL). This is well below 8 mmol/L (144 mg/dL), and therefore there’s a significant risk for hypos. Given how quickly he was responding to the diet, I decided to completely stop his insulin.
In the days after discontinuing insulin, his blood sugar levels were all between 5.6 mmol/L (101 mg/dL) and 10 mmol/L (180 mg/dL). Great! I thought. Now let’s start working on gliclazide, which does nothing to help patients improve their insulin resistance or lose weight. We were able to completely stop it the following week, as his blood sugar levels kept dropping.On October 26, he had his first official follow up with my nurse. His weight was down to 262 pounds (119 kg), his fasting blood sugar was 11.5 mmol/L (207 mg/dL) that day, and his blood pressure was 137/77. He was surprised that his blood pressure would be going down, because I had told him to increase his sodium intake, which he had agreed to do, but he had been hesitant and skeptical. He mainly noted that he was less hungry, his sleep was better, and his energy levels were starting to improve. He had started reducing his eating window by skipping breakfast.
Continued weight loss, health improvement, and medication reduction
On November 8, Dennis’s weight was down to 252 pounds (115 kg), his blood pressure was 126/75, his fasting blood sugar level was 9.6 mmol/L (173 mg/dL), with lower values postprandially, and his blood ketone level was 1.0 mmol/L. He mentioned being less and less hungry, and having the best sleep of his life.
On November 22, his weight was 244 pounds (111 kg) and his blood pressure was between 98/66 and 127/74. He was feeling dizzy sometimes. It was time to cut some of his hypotensive medication! We stopped his amlodipine. I try to save the ACE inhibitors for last (check out Dr. Westman, et al.’s, excellent explanation on the topic in this article).On December 19th, his weight was 232 pounds (105 kg) and blood pressure was 104/70. He felt like he was no longer dieting but eating healthy, and he was enjoying fasting intermittently. Something else was improving: his chronic pain was significantly reduced, especially in his knees.
I told him to cut his ACE inhibitor by 50%. If possible, I keep this medication until all renal function is back to normal (normal glomerular filtration rate and absence of microalbuminuria or protein in the urine), diabetes is completely resolved, and blood pressure is completely normal, as long as patients do not have symptoms of hypotension. Some patients will therefore remain on a small dose, as we’re not always able to reverse all damage, and some patients will have to stop taking it early due to symptoms of hypotension.
His liver ultrasound report arrived at that time showing an enlarged liver with evidence of fatty liver and fatty pancreas. This is very common in people with type 2 diabetes, and it’s the reason we do ultrasounds when they start and six months later. Some patients sometimes have begun to show signs of cirrhosis, and they are not even aware. We have had to refer quite a few patients to hepatologists.
The patient asked my nurse if he could stop his statin, because his lipid profile was normal. I replied that we certainly could, with a check in eight weeks to see what would happen. But because Denis is not my patient outside of his participation in our 6-month program, I told him he might want to wait until he’d stabilized his weight for at least 6 to 12 months. I did not want his family doctor to freak out if the results were abnormal and call him to tell him to stop this “dangerous diet” right away, as it’s happened in the past with a few patients.1
We have found that lipid panels don’t show optimal values until someone has lost all their excess weight and has had a stable weight for a few months. In any case, I believe the most important thing is to inform patients of the pros and cons, and help them make an informed decision.
On January 17, after the holidays, Denis was still going strong. His weight was 222 pounds (101 kg), his blood sugar levels were mainly around 7 mmol/L (126 mg/dL), rarely around 10 mmol/L (180 mg/dL)., and his blood ketone levels were almost always around 1.0 mmol/L. His blood pressure was 117/76, and his chronic pain, especially in his legs, was almost all gone.On February 14, we compared his blood tests from October and February. His fasting insulin went from 240 pmol/L to 50 pmol/L! He mentioned that because his pain was gone, he was more willing and able to move, and as a result he started walking more and being more active. He was feeling great!
On February 22, we were able to stop his saxagliptin. His metformin was down to 850 mg once a day (He kept on skipping doses on the days he was fasting, so along the way, it just became once a day).
Denis just kept on going. He was lucky to have the full support of his wife, who happened to be quite a chef in the kitchen! Denis was eating the best food of his life, and never suffered hunger ever again.
After nine months of keto, “a new lease on life”
After his program was done, he knew just what to do to continue reversing his diabetes and obesity. Nine months later, he had stopped all medication, except a small dose of ACE inhibitor, and got a second liver ultrasound. His blood sugar levels were normal. We met again, for his final medical visit.
His u/s reported “a very significant improvement where steatosis phenomena has almost completely disappeared.” His fasting insulin was now 43 pmol/L, and he had lost a total of 84 pounds (38kg) and 10 inches (25 cm) from his waist.
Denis said that the implementation of this new way of eating had not been easy, as this approach is against the common knowledge he had been taught since childhood: that fat is bad and that carbohydrates, at least complex carbohydrates, are allies. He had to relearn how to eat, to adjust to not always being hungry, to be comfortable with periods of not eating, to no longer be afraid of exercise-induced hypoglycemia, and to appreciate previously demonized nutrients.
It was important for Denis to be well-supported and well-informed. It was also essential for him to have a specific goal of curing his diabetes and stopping all his medications. Understanding how metabolism works was a helpful key: when Denis realized it wasn’t he who decided his weight but his body, this knowledge convinced him to consume only what his body needed to do the work: very little carbohydrate, and at the right time, with intermittent fasting.
When Denis went back to see his family doctor after nine months, she said, “You’re healthy now, I don’t need to see you for another year!” Previously, he had seen his doctor every threee months for 30 years. For Denis, this has been a nice reward, and has provided him with a new life. The only health concern Denis is still dealing with is slightly high blood pressure, which is resolving as continues to progress.
As he and his wife were sitting in front of me in my office, the three of us got teary-eyed, with huge smiles on our faces at the same time. It was like a rainbow. Denis warmly thanked me for helping him get a new lease on life, and his beaming wife said she’s gotten back the man she had married. And I thanked them for trusting me with his life. Being a doctor and helping people regain their health and their future with proper nutrition and lifestyle habits is a true privilege.
Low carb & keto for clinicians
GuideAre you a doctor or do you know a doctor? Are you interested in low carb and keto diets? Then this resource could be something for you to use or share!
It is commonly noted that LDL cholesterol can increase during active weight loss and frequently decreases with weight stability ↩