Dieting Osteogenesis Imperfecta and Keto Muscle Building

So once again I’m taking the lazy way out and going to the mailbag for a quick and dirty article.

Question: Hi Lyle, I am a big fan of your work and I have an important question. So I have ulnar nerve subluxation in my left arm and I am restricted in my training. I choose to avoid any pressing movements such as any bench press, any tricep movement, and any shoulder press. Every other lift I can do, I am cutting now and I am wondering what is the best way to go about preserving my muscle mass without bench press/shoulder press/tricep movements? Should I stick to heavy chest flies and Heavy shoulder raises? What about triceps? Thanks so much Lyle.

Answer: I wouldn’t diet while injured would be my suggestion unless you can find something workable for those muscles group.  You will lose muscle in them without some type of training stimulus.  If you’re determined to diet either accept the muscle loss or, I dunno, maybe isometrics of some sort.  It’s better than nothing.  Or see if what I’m going to talk about in the next question is workable.

Question: Dear Mr. McDonald, I´m writing this e-mail to you because I don´t know what to do anymore and neither do the “specialists” that I´ve already consulted. I was born with a gene deficiency called “Osteogenesis Imperfecta Type 1” or brittle bone disease. Luckily, it´s only Type 1, the mildest of all types (if I had any of the other types training in general would probably be off the table…). In short this means that my body has a malfunction regarding the production of collagen tissues (type 1) which pretty much can be found in almost all types of structures the human body consists of, but most of it can be found in the bones – that´s why they break easier and also why it´s called brittle bone disease.

Answer: The above question was much longer but mostly a reiteration of the above so I cut it for length.  First and foremost, I’m not a doctor and I don’t even play one on television so take my comments under that clarification.  However, I do think I can offer a bit of input on this.

In recent years, there has been a progressive amount of research showing that lighter load, higher repetition work can be as effective (but not better) than heavy training for growth and this is true in both untrained and trained individuals.

Now, for the most part, I don’t think too highly of this type of training (or Blood Flow Restriction/Kaaaaatsuuuu training despite it’s current faddish popularity) for hypertrophy, at least not as a primary training method.    It’s painful as hell (in Brad’s studies, several subjects threw up), it doesn’t generate more growth, doesn’t improve strength and there is another issue I’ll mention in a second.

However, there are a handful of situations where I do think it can be useful.  In older folks, where a lot of this was first trialed, it can offer a training stimulus that deliberately reduces joint and bone loading.  The same holds for injuries (after a low back injury, I once limited myself to single set Superslow training for a while to get a muscular stimulus without putting high peak forces through my spine).  And I think in this specific situation it might play a role.  Since OI is a disease of brittle bones, this type of training should allow a sufficient muscular stimulus while deliberately reducing bone loading forces.

But this brings up the issue I said I’d mention which is actually strengthening the bones.  This requires fairly high absolute or peak loading (athletes who do a lot of jumping or sprinting have higher bone density than even powerlifters who generate high but more extended forces; endurance athletes are the worst off) and I don’t think low load/BFR training will generate that.

And I don’t know what the solution here is except perhaps to take the VERY long approach of starting with light load training and gradually reducing the repetition range.  I’m talking over months and months with the repetitions gradually coming down and it might take longer than that.  Bone mineral density (BMD) develops very slowly and I don’t even know if it can occur at all in OI.   It might realistically take a year or more to gain even a few percent although I might expect this to be faster in already brittle bones.

So 25-35 reps to failure for 3-4 months or until joint or bone pain stops.  Now move to 20-25 reps for 3-4 months or until joint or bone pain stops.  Now move to 15-20 reps for 3-4 months.  The 10-15 repetitions.  By the time you get to the 8-12 range, it’s heavy enough to have a benefit on bones (and note that muscular pull, using different angles plays a role in this).

Hopefully with each gradual increase in loading and decrease in repetitions there will be slightly more bone loading.  This should go along with proper nutrition which includes sufficient dietary protein, calcium, Vitamin D, Vitamins K1 and K2 and veggies.  I also know that they have been trialing various drugs, often anabolic steroids for increasing bone density but this is beyond what I can talk about meaningfully.

Question: Hello Lyle. I’m an avid (“student”) reader of yours. I wanted to throw a question at you on building muscle on a diet with very little carbs. From what I have gathered, the body burns a certain percentage of fat and carbs for energy. For example: as you are reading this your body, supposedly, is burning around 60% fat and 40% carbs. At rest, the body burns roughly 33% carbs and the rest fat. So on, and so on . . . I had read through biology that the body cannot burn 100% fat. So, if there are very little to no carbs, then the body burns the amino acids in its place. (Yes? No?) Do you have any info that explains how the body is able to not only keep the muscle but build it through weightlifting if it is burning all of those amino acids??? From a biological point of view, it just doesn’t make sense. Unless the body does indeed burn at or near 100% fat. But I could not find any sources on that. Maybe people just need to eat 50-100 more grams of protein, especially when on a ketosis diet???

Answer:  The actual subject line of this question was “Question on how the body builds muscle without carbs?” and my short answer answer to that is “poorly.” based on the overall hormonal profile that occurs with very low-carbohydrate diets.

You see increased cortisol, increased binding of testosterone to SHBG and a host of others and here’s an amusing bit of trivia.  In the only study I’m aware of, women with intractable epilepsy were put on a maintenance level ketogenic diet.  And every single one of them, I mean 100% developed menstrual cycle disorders.  Because even at maintenance calories, a ketogenic diet is still biologically a starvation state no matter how you cut it.

But clearly there’s a bit more to his question (and note that all of this is discussed in painful detail in my first book The Ketogenic Diet).

The problem with what is written above is the idea that the body is burning nearly that much body protein for energy simply because carbs aren’t available.  Certainly, it is true that the production of glucose from protein increases when carbohydrate intake is very low (below about 100-120 grams per day which is the cutoff for the development of ketosis).  In fact, during complete starvation (the ultimately low-carbohydrate state), the loss of body protein is extremely high.

For about three weeks anyhow.

Before expanding on that, let me back up a bit.  Most tissues in the body can use glucose or fatty acids for fuel (and the switch back and forth is called metabolic flexibility) although glucose is the preferred fuel by most if it is available.    There are a few exceptions.  The heart uses fatty acids and this is to ensure that there is enough fuel available.

A few odd others like the eye and some part of the kidney and one other that I can’t remember right now can only use glucose (but it comes from the recycling of things like lactate).   But muscle and most other tissues in the body can switch back and forth as needed (requirements also change during exercise).

And then there is the brain.  It’s usually stated that the brain can only use glucose for fuel (to the tune of about 80-120 grams per day) but it’s more accurate to say that it can’t use fatty acids. Which seems like the same thing but isn’t because there is an alternate fuel that is available: ketones (aka ketone bodies, aka ketoacids).

Ketones are made in the liver when fat oxidation goes up beyond a certain degree and this generally happens when carbohydrate is extremely low (other nutrients also play a role).  The cutoff is the same 80-120 grams/day that defines the brains normal carbohydrate requirements and this is what defines a ketogenic diet.

Yes, most low-carbohydrate diets set carb intake levels lower, 30-50 grams of carbohydrate but this is more of a practical issue than a biological issue.  Physiologically, any carb intake below ~100 grams per day will induce some degree of ketosis (defined as a blood concentration of ketones above a certain point that I don’t recall at the moment) with more ketones being produced if carbohydrate intake is lower.

And the entire point of ketones is to spare body protein in the situation where carbohydrates aren’t available.  So imagine someone is starving completely, eating nothing.  For about 3 weeks their use of body protein for the production of glucose will be enormous and they will be losing a lot of body protein (note that this is impacted on enormously by body fat percentage, the more fat someone is carrying the less protein they use for fuel which is why I always scale my dietary recommendations based on body fat percentage).

If that body protein loss continued unabated, they’d lose a lot of muscle, their bodies would start to eat their organs and they would eventually die.  And that would be bad.  So the body shifts its metabolism, primarily the brain to using ketones.  Over roughly three weeks, the brain will use more and more ketones until it derives roughly 75% of it’s total fuel from them, the other 25% has to come from glucose and this will come from protein breakdown.

Under starvation conditions, that means body protein will still be broken down for energy.  But the energy can also come from dietary protein; this is a big part of why protein requirements go UP when someone is dieting: some of the protein is being used for energy so more has to be eaten.

And by that point, the grand majority of energy in the body will be coming from fatty acids (in most tissues), ketones (in the brain) with some glucose still being used by the brain and a few other odd tissues that can’t use fatty acids or ketones.  So the idea that an enormous amount of protein is being used for energy under these conditions is only true for a little while.

So long as someone increases dietary protein, this offsets the bodies need to use body protein for fuel.  Which still isn’t to say that I think a ketogenic diet, even on high calories is optimal for mass gains.  It’s still biologically a starvation state in a hormonal sense even if you’re eating lots of food and the overall hormonal profile for mass gains will be superior even on moderate carbohydrates comparatively speaking (there are also cyclical ketogenic diets but that’s beyond the scope of this).

But the idea that the body is burning tons and tons of protein, which was the real gist of your question, isn’t correct due to the overall shift in metabolism from glucose to fatty acids/ketones over about 3 weeks of adaptation.  I still don’t think ketogenic diets are OPTIMAL for building muscle growth.  They can work (especially if they are used cyclicall) but even moderate carb diets tend to produce a better/more anabolic hormonal response in this regard.

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