Fasting/Ketosis for cognition

[TwoHighways]

Doing a little experiment going into my exam tomorrow. We’ll see how it plays out. I’m a nutritional ketosis enthusiast and should be above 5 mmol by tomorrow morning with glucose down to the mid to upper 60’s. Just tested and am currently at 3.4 mmol beta hydroxybutrate and 78 mg/dL on glucose. It usually takes longer to flip the switch so to speak, as I’m only approaching 36 hours of fasting, but I had a pretty good workout yesterday morning which I’m sure helped speed the process along. I’ve done 60-72 hour fasts previously and when BHB overtakes glucose on a mmol basis, the mentality clarity that comes with it is a bit surreal.

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[Wordead]

It's called delirium

 

[Chlorini]

I do a 36 hour fast once a week and I intermittent fast for the remainder of the week. I've been doing this off and on for years. I never fasted before/during an exam, mostly because I sleep poorly during fasts (wide awake!). I think fasting during studying would be beneficial, not sure if I would risk it during an exam. However, I never eat before a test or get coffee (I don't want the carb fog and I don't want to use the bathroom). That always worked out well for me. My stomach growls would be annoying/embarrassing, but I never cared. Good luck, let us know how it turns out.

 

[TwoHighways]

It felt awesome! Locked in and no anxiety. Just stayed in the moment taking each question in stride and not focusing on previous questions I was unsure of. And this was actually going on a crappy night’s sleep (memory foam is awful, don’t know why people like this stuff). Can’t wait for my replacement mattress to arrive. I think it’s a viable strategy for me going forward. YMMV

 

[Styrene]

I eat only one meal per day, which is dinner, low carb, and that only takes about 15-20 minutes to eat. I drink one to two liters of water with the meal. Sometimes I drink half to one liter of water when I wake up, depending on thirst. Other than that, absolutely nothing. I don't even need water during the day. I am able to work for 12 hours straight or even longer with no breaks at all and without feeling the slightest bit fatigued or unfocused.

I was on this same eating pattern during Step 1, as well. I finished the test in 4.5 hours with only one three-minute break after the fourth section to use the bathroom and put in eye drops.

I've ate in this pattern for a long time, so I can't comment on differential testing performance between intermittent fasting vs "three meals per day," which is a sociocultural construct that is out of touch with human evolution.

 

[TwoHighways]

I eat only one meal per day, which is dinner, low carb, and that only takes about 15-20 minutes to eat. I drink one to two liters of water with the meal. Sometimes I drink half to one liter of water when I wake up, depending on thirst. Other than that, absolutely nothing. I don't even need water during the day. I am able to work for 12 hours straight or even longer with no breaks at all and without feeling the slightest bit fatigued or unfocused.

I was on this same eating pattern during Step 1, as well. I finished the test in 4.5 hours with only one three-minute break after the fourth section to use the bathroom and put in eye drops.

I've ate in this pattern for a long time, so I can't comment on differential testing performance between intermittent fasting vs "three meals per day," which is a sociocultural construct that is out of touch with human evolution.

I’m pretty much OMAD as well except on heavy lift days. I’m quite tolerant of carbs post workout likely mediated by AMPK (glut4 translocation independent of insulin), and that’s when I take full advantage of the activation of that pathway to rapidly replenish glycogen stores while actually staying in ketosis. This stuff is absolutely fascinating to me, and someday it’ll be seen as more than just a fad. The literature is out there for anyone that actually wants to learn about it and it’s not that hard of a thing to adopt.

 

[Bacchus]

I eat only one meal per day, which is dinner, low carb, and that only takes about 15-20 minutes to eat. I drink one to two liters of water with the meal. Sometimes I drink half to one liter of water when I wake up, depending on thirst. Other than that, absolutely nothing. I don't even need water during the day. I am able to work for 12 hours straight or even longer with no breaks at all and without feeling the slightest bit fatigued or unfocused.

I was on this same eating pattern during Step 1, as well. I finished the test in 4.5 hours with only one three-minute break after the fourth section to use the bathroom and put in eye drops.

I've ate in this pattern for a long time, so I can't comment on differential testing performance between intermittent fasting vs "three meals per day," which is a sociocultural construct that is out of touch with human evolution.

Someone get this guy an iStat BUN/Cr.

 

[ChopinLiszt]

I think we all need to know what you’re eating at this one meal a day. I’m hoping it includes eggs, bacon, soup and a sandwich, and kung pao chicken/fried rice

 

[Espressso]

I’m pretty much OMAD as well except on heavy lift days. I’m quite tolerant of carbs post workout likely mediated by AMPK (glut4 translocation independent of insulin), and that’s when I take full advantage of the activation of that pathway to rapidly replenish glycogen stores while actually staying in ketosis. This stuff is absolutely fascinating to me, and someday it’ll be seen as more than just a fad. The literature is out there for anyone that actually wants to learn about it and it’s not that hard of a thing to adopt.

I assume you know of Peter Attia and his podcast, The Drive? Big time-restricted eating guy

 

[TwoHighways]

I assume you know of Peter Attia and his podcast, The Drive? Big time-restricted eating guy

Not all heroes wear capes. I admire the **** out of that guy! Wish he had a bigger audience/following.

 

[Espressso]

Not all heroes wear capes. I admire the **** out of that guy! Wish he had a bigger audience/following.

Yeah, he's great. He's the reason I got into fasting/TRE in the first place years ago. Legit was pre-diabetic way back when before I started and heard about him.

 

[LunaOri]

It's called delirium

Also known as "mentality clarity"

 

[TwoHighways]

What evolutionary benefit would delirium have provided our ancestors as they went days without food? (which was likely a frequent occurrence before the dawn of agriculture) If anything, they needed to be sharper and more in tune with their environment as their very survival depended on it. We're literally fatter and more metabolically deranged than ever as a country, and people still dismiss the idea of fasting, let alone any potential cognitive benefits it may bring. Maybe an honest assessment of your own labs/metabolic profile is in order. 2/3 of "normal" weight people aren't metabolically healthy according the linked study.

https://www.liebertpub.com/doi/10.1089/met.2018.0105

 

[longhaul3]

What evolutionary benefit does delirium provide ever? It's not an adaptive physiologic response. It's a pathologic state reflecting acute-onset brain dysfunction, like you might expect when nutrients become unavailable.

That's like asking what evolutionary benefit a pcom aneurysm or DKA provided our ancestors. They just died. Medicine exists to address what we deem unacceptable shortcomings of nature and evolution.

 

[TwoHighways]

What evolutionary benefit does delirium provide ever? It's not an adaptive physiologic response. It's a pathologic state reflecting acute-onset brain dysfunction, like you might expect when nutrients become unavailable.

That's like asking what evolutionary benefit a pcom aneurysm or DKA provided our ancestors. They just died. Medicine exists to address what we deem as unacceptable shortcomings of nature and evolution.

Starvation induced delirium doesn’t manifest over 72 hours, days, or even weeks or months depending on the amount of adipose one has to burn through. If our ancestors went into delirium that quickly from a lack of food, we wouldn’t be around today. On the contrary, going without food likely sharpened their senses. Obviously not indefinitely, but having access to food 24/7/365 is not normal or conductive to optimal metabolic health as evidenced by the lack of metabolic health plaguing the USA and increasingly around the world.

 

[Matthew9Thirtyfive]

Starvation induced delirium doesn’t manifest over 72 hours, days, or even weeks or months depending on the amount of adipose one has to burn through. If our ancestors went into delirium that quickly from a lack of food, we wouldn’t be around today. On the contrary, going without food likely sharpened their senses. Obviously not indefinitely, but having access to food 24/7/365 is not normal or conductive to optimal metabolic health as evidenced by the lack of metabolic health plaguing the USA and increasingly around the world.

I think it’s a bit of a stretch to say that eating every day is the reason we have an obesity problem in this country and in other countries.

 

[TwoHighways]

I think it’s a bit of a stretch to say that eating every day is the reason we have an obesity problem in this country and in other countries.

I’d be inclined to agree if the food consumed isn’t abject garbage. There’s a case to be made that three meals a day is not optimal for metabolic flexibility, particularly if all three meals have significant carbohydrate, which would lead to inefficient fat metabolism and storage over time. The crappier the food, the greater the benefit there is in fasting for optimal metabolic health, which consists of suppressing insulin and depleting liver glycogen stores periodically to the point where ketones are produced as a product of increased fat oxidation in the liver (BHB is an HDAC inhibitor and important signaling molecule that researches are just starting to look into).

 

[Matthew9Thirtyfive]

I’d be inclined to agree if the food consumed isn’t abject garbage. There’s a case to be made that three meals a day is not optimal for metabolic flexibility, particularly if all three meals have significant carbohydrate, which would lead to inefficient fat metabolism and storage over time. The crappier the food, the greater the benefit there is in fasting for optimal metabolic health, which consists of suppressing insulin and depleting liver glycogen stores periodically to the point where ketones are produced as a product of increased fat oxidation in the liver (BHB is an HDAC inhibitor and important signaling molecule that researches are just starting to look into).

You’re moving the goalposts. It’s totally possible to eat healthy and eat every day. Lots of people do it.

 

[TwoHighways]

You’re moving the goalposts. It’s totally possible to eat healthy and eat every day. Lots of people do it.

I eat most days. I’ll give you that, you can certainly never go without food for more than a day and be healthy (though I question how most would define “healthy”, given how unhealthy the majority of the population is). I just find it laughable that people write it off extended fasting when it would correct a lot of the metabolic dysfunction driving a huge amount of our healthcare spending or discount any cognitive benefit that may be provided by increased ketones in circulation. Certainly plenty of Alzheimer’s patients that have benefited.

 

[Wordead]

I eat most days. I’ll give you that, you can certainly never go without food for more than a day and be healthy (though I question how most would define “healthy”, given how unhealthy the majority of the population is). I just find it laughable that people write it off extended fasting when it would correct a lot of the metabolic dysfunction driving a huge amount of our healthcare spending or discount any cognitive benefit that may be provided by increased ketones in circulation. Certainly plenty of Alzheimer’s patients that have benefited.

Thats some good broscience man

 

[Mass Effect]

I eat only one meal per day, which is dinner, low carb, and that only takes about 15-20 minutes to eat. I drink one to two liters of water with the meal. Sometimes I drink half to one liter of water when I wake up, depending on thirst. Other than that, absolutely nothing. I don't even need water during the day. I am able to work for 12 hours straight or even longer with no breaks at all and without feeling the slightest bit fatigued or unfocused.

I was on this same eating pattern during Step 1, as well. I finished the test in 4.5 hours with only one three-minute break after the fourth section to use the bathroom and put in eye drops.

I've ate in this pattern for a long time, so I can't comment on differential testing performance between intermittent fasting vs "three meals per day," which is a sociocultural construct that is out of touch with human evolution.

 

[Mass Effect]

Starvation induced delirium doesn’t manifest over 72 hours, days, or even weeks or months depending on the amount of adipose one has to burn through

What? Are you suggesting that a patient who is obese can go several weeks/months without eating without any cognitive affects because they have "adipose to burn through"?

 

[Matthew9Thirtyfive]

What? Are you suggesting that a patient who is obese can go several weeks/months without eating without any cognitive affects because they have "adipose to burn through"?

I know I get pretty delirious if I don’t eat for a couple days, but I guess that’s cause I’m skinny.

 

[Styrene]

What? Are you suggesting that a patient who is obese can go several weeks/months without eating without any cognitive affects because they have "adipose to burn through"?

Yes, they can, as long as proper micronutrients are provided. There is even a man who went one year eating almost nothing and lost several hundred pounds.

 

[Chlorini]

What? Are you suggesting that a patient who is obese can go several weeks/months without eating without any cognitive affects because they have "adipose to burn through"?

Yes. I actually just watched a Netflix special (UnWell) about this. I think the lady they showed went an entire month without food--just water. She lost 30ish pounds. They contrasted her story with another guy who did a water fast (he didn't have much to lose) and he went delirious, fell, suffered a bleed and died. He was being followed by a holistic guy who believed "MDs are poisoned by their medical knowledge." It was very entertaining to watch, highly recommend.

I've completed a 5 day water-only fast in college (and I'm very fit). I wasn't killing myself in the gym, I took electrolytes. It was hard but the mental clarity was crazy. TBH, once you're in ketosis you aren't hungry. The first 17-18 hours are the hardest which actually makes complete sense-- that's approximately how long it takes to go into ketosis.

I think people should at least try to fast for 24-36 hours once in their life; just to see. Even if you don't believe in fasting, I just think it's an accomplishment to not focus on food for a set amount of time. When I'm with someone who says "oh man I'm starving, I need food ASAP" when I haven't eaten for 36 hours, it puts things into perspective. It's a self-control thing. We, as a nation, are obsessed with food.

 

[Mass Effect]

Yes. I actually just watched a Netflix special (UnWell) about this. I think the lady they showed went an entire month without food--just water. She lost 30ish pounds. They contrasted her story with another guy who did a water fast (he didn't have much to lose) and he went delirious, fell, suffered a bleed and died. He was being followed by a holistic guy who believed "MDs are poisoned by their medical knowledge." It was very entertaining to watch, highly recommend.

I've completed a 5 day water-only fast in college (and I'm very fit). I wasn't killing myself in the gym, I took electrolytes. It was hard but the mental clarity was crazy. TBH, once you're in ketosis you aren't hungry. The first 17-18 hours are the hardest which actually makes complete sense-- that's approximately how long it takes to go into ketosis.

I think people should at least try to fast for 24-36 hours once in their life; just to see. Even if you don't believe in fasting, I just think it's an accomplishment to not focus on food for a set amount of time. When I'm with someone who says "oh man I'm starving, I need food ASAP" when I haven't eaten for 36 hours, it puts things into perspective. It's a self-control thing. We, as a nation, are obsessed with food.

It's not lack of self control that keeps people from not going 36 hours without food. I'm a psychiatrist and I'm more than a little worried that doctors-to-be believe it's healthy to go one month without food.

 

[VA Hopeful Dr]

It's not lack of self control that keeps people from not going 36 hours without food. I'm a psychiatrist and I'm more than a little worried that doctors-to-be believe it's healthy to go one month without food.

It's not inherently healthy but it can be done safely if you do it right.

 

[Chlorini]

It's not lack of self control that keeps people from not going 36 hours without food. I'm a psychiatrist and I'm more than a little worried that doctors-to-be believe it's healthy to go one month without food.

I didn't say that I thought it was healthy to go one month without food, lol. I'm just saying it can be done. And a 36 hour fast is really easy (last meal around 6-7 PM the previous day, fast the entire next day, break the fast the next morning). Some people probably do this by accident all the time.

My own sister lost 60 lbs by intermittent fasting. The results can be incredible if you're open to the idea.

 

[LunaOri]

Yom Kippur once a year is enough fasting for me.

 

[Mass Effect]

It's not inherently healthy but it can be done safely if you do it right.

Is there evidence of health benefits of not eating actual food for one month?

I didn't say that I thought it was healthy to go one month without food, lol. I'm just saying it can be done. And a 36 hour fast is really easy (last meal around 6-7 PM the previous day, fast the entire next day, break the fast the next morning). Some people probably do this by accident all the time.

My own sister lost 60 lbs by intermittent fasting. The results can be incredible if you're open to the idea.

Intermittent fasting isn't going a month without food, as far as I know. Is there evidence of going one month without food being beneficial (weight loss on its won doesn't equal beneficial)?

 

[VA Hopeful Dr]

Is there evidence of health benefits of not eating actual food for one month?



Intermittent fasting isn't going a month without food, as far as I know. Is there evidence of going one month without food being beneficial (weight loss on its won doesn't equal beneficial)?

Actually, weight loss on its own DOES equal beneficial. That's one of the main purposes behind fasting.

Most people don't fast for that long because to not have health issues you have to be very careful about taking vitamins/minerals since that long of a fast will result in electrolyte abnormalities otherwise.

But there are lots of people who do several day fasts. There's a thread in SPF where a few of the folks there detail their 3-7 day fasts.

 

[TwoHighways]

Improved metabolic profile. Plummeting triglycerides. Improvement of Trig/HDL ratio (which is a superior risk factor for development of cardiovascular disease compared to LDL-C). Lowered average blood glucose. Gain in metabolic flexibility (ability to metabolize free fatty acids, which type 2 diabetics show a resounding inability to do looking at respiratory quotients) Reduced inflammation. Reduced circulating insulin. Promotion of autophagy. Mitochondrial biogenesis. Reversal of type 2 diabetes. Potential anti-cancer effects. But nah, fasting is stupid and no one should ever do it, regardless of their metabolic health.

 

[Mass Effect]

Actually, weight loss on its own DOES equal beneficial

As a psychiatrist, I don't see that to be the case. The patients I see who fast in order to lose weight almost always have electrolyte abnormalities or a BMI that is dangerously unhealthy. So when I see weight loss, that's only a very small part of the story. Until I see electrolytes, vitamin levels, and get nutritional history, I don't consider it to be healthy. Anyone can lose weight. It doesn't mean all weight loss is healthy.

That's one of the main purposes behind fasting

Intermittent fasting, sure. But I'm specifically talking about not eating for one month. When a person doesn't eat for one month with the purpose of losing weight, they're teetering very close to a mental illness diagnosis.

Most people don't fast for that long because to not have health issues you have to be very careful about taking vitamins/minerals since that long of a fast will result in electrolyte abnormalities otherwise.

Right, which is why I think it's a crazy part of the discussion. I mean, anything can be safe. I could stand on train tracks and do it in a safe way as long as I do it at certain times, make sure to stay alert, make sure I leave the tracks before a train, etc, but it doesn't mean it should be done. A month long restriction of food is not something I would ever advise.

But there are lots of people who do several day fasts. There's a thread in SPF where a few of the folks there detail their 3-7 day fasts.

Right, I'm well aware. I was specifically talking about not eating anything for one month.

 

[VA Hopeful Dr]

As a psychiatrist, I don't see that to be the case. The patients I see who fast in order to lose weight almost always have electrolyte abnormalities or a BMI that is dangerously unhealthy. So when I see weight loss, that's only a very small part of the story. Until I see electrolytes, vitamin levels, and get nutritional history, I don't consider it to be healthy. Anyone can lose weight. It doesn't mean all weight loss is healthy.



Intermittent fasting, sure. But I'm specifically talking about not eating for one month. When a person doesn't eat for one month with the purpose of losing weight, they're teetering very close to a mental illness diagnosis.



Right, which is why I think it's a crazy part of the discussion. I mean, anything can be safe. I could stand on train tracks and do it in a safe way as long as I do it at certain times, make sure to stay alert, make sure I leave the tracks before a train, etc, but it doesn't mean it should be done. A month long restriction of food is not something I would ever advise.



Right, I'm well aware. I was specifically talking about not eating anything for one month.

Yes but for those of us who treat diabetes, hypertension, and hyperlipidemia weight loss can reverse those things so its worth doing. You're correct that not all weight loss is healthy which is why month-long fasts are very very rare. Most people do more like 2-5 at most.

I also don't recommend month long fasts. I never said I did. My entire point in joining this thread is to say that it can be done in a safe way. That was literally it. I stand by that because we have evidence of it being done safely and those methods being repeated by others also safely.

 

[Mass Effect]

Yes but for those of us who treat diabetes, hypertension, and hyperlipidemia weight loss can reverse those things so its worth doing. You're correct that not all weight loss is healthy which is why month-long fasts are very very rare. Most people do more like 2-5 at most

Again, I'm not talking about fasts that are 2-5 days. I am exclusively talking about month-long fasts and I disagree that the weight loss is worth the potential negative consequences. There are many other healthier ways to lose weight and treat the things you mentioned.

 

[Gilakend]

Med students 25 years ago: I better read this chapter again before the test.

Med students today: I just need to peak at 5.4763 mmol beta hydroxybutrate and I'll be ready for this test

 

[VA Hopeful Dr]

Again, I'm not talking about fasts that are 2-5 days. I am exclusively talking about month-long fasts and I disagree that the weight loss is worth the potential negative consequences. There are many other healthier ways to lose weight and treat the things you mentioned.

You keep making arguments against points I'm not making

 

[Neopolymath]

You keep making arguments against points I'm not making

I keep re-reading the thread trying to understand how we got here...

 

[Matthew9Thirtyfive]

I keep re-reading the thread trying to understand how we got here...

Some of you have never fasted for a month and it shows.

 

[Mass Effect]

You keep making arguments against points I'm not making

I feel like it's the other way around. I've repeatedly said I'm talking only about a month-long fast and you keep telling me about 2-7 day fasts. They have nothing to do with my point which is that the potential negative consequences of a one-month fast in most patients make it unsafe in my view and not something I would recommend, regardless of any benefit of weight loss. That's all I'm saying.

 

[Matthew9Thirtyfive]

I feel like it's the other way around. I've repeatedly said I'm talking only about a month-long fast and you keep telling me about 2-7 day fasts. They have nothing to do with my point which is that the potential negative consequences of a one-month fast in most patients make it unsafe in my view and not something I would recommend, regardless of any benefit of weight loss. That's all I'm saying.

I feel like you guys are just angrily agreeing with each other.

 

[Mass Effect]

I feel like you guys are just angrily agreeing with each other.

Agreed.

 

[futureapppsy2]

The human literature on non-extreme water fasting (one week or less) and IF is mixed, with some studies showing positive effects in health indicators (FBG, blood pressure, cholesterol, weight, etc) and others showing no effects. One considerable caveat is that most of these studies have been done with obese patients only, so we don't necessarily know how it impacts normal weight individuals or those who are only slightly overweight. Some emerging research suggests that women do better with shorter fasting times and men do better with longer fasting times. I do IF, both 16/8 or longer and periodic 32-48 fasts, but the literature is much less definitive than IF advocates would lead you to believe

(I will say that I've always found the idea that extremely long-term drastic calorie restriction is the key to staving off disease and increasing longevity to be kind of odd, because people with anorexia would then by pictures of health rather than riddled with serious, and potentially fatal health issues).

 

[TwoHighways]

The human literature on non-extreme water fasting (one week or less) and IF is mixed, with some studies showing positive effects in health indicators (FBG, blood pressure, cholesterol, weight, etc) and others showing no effects. One considerable caveat is that most of these studies have been done with obese patients only, so we don't necessarily know how it impacts normal weight individuals or those who are only slightly overweight. Some emerging research suggests that women do better with shorter fasting times and men do better with longer fasting times. I do IF, both 16/8 or longer and periodic 324-48 fasts, but the literature is much less definitive than IF advocates would lead you to believe

(I will say that I've always found the idea that extremely long-term drastic calorie restriction is the key to staving off disease and increasing longevity to be kind of odd, because people with anorexia would then by pictures of health rather than riddled with serious, and potentially fatal health issues).

When you’re catabolizing your own lean body mass in the form of skeletal muscle, you’ve clearly taken it too far. Don’t think anyone here has advocated fasting to the extremes of literally wasting away. If you’re morbidly obese, you can go a hell of a long time without eating as several case studies show. We don’t really have a formula as to how often one should fast and for what duration, but it’s clearly a powerful tool that corrects the underlying physiology of the metabolic syndrome which is bringing about the premature deaths of thousands upon thousands of Americans each year and is by far the biggest public health problem in our country.

 

[VA Hopeful Dr]

Agreed.

 

[hamstergang]

the potential negative consequences of a one-month fast in most patients make it unsafe in my view and not something I would recommend, regardless of any benefit of weight loss

Did anyone in this thread recommend a 1 month fast in any patient, let alone most patients?

I don't know what to believe about fasting, but those advocating for it in this thread seem to be talking about doing it deliberately with attention paid to how to avoid the negative consequences you bring up. As a psychiatrist literally sitting in an eating disorders program as I type this, I don't know why you keep mentioning that you are a psychiatrist as if that negates these other factors.

 

[kepler16b]

I keep re-reading the thread trying to understand how we got here...

The is the most classic case of moving goalposts that I have seen on SDN, lol.

 

[Mass Effect]

Did anyone in this thread recommend a 1 month fast in any patient, let alone most patients?

I never said they did, but touting the benefits of it also warrants discussion.

I don't know what to believe about fasting, but those advocating for it in this thread seem to be talking about doing it deliberately with attention paid to how to avoid the negative consequences you bring up. As a psychiatrist literally sitting in an eating disorders program as I type this, I don't know why you keep mentioning that you are a psychiatrist as if that negates these other factors.

I mention I'm a psychiatrist because I believe that going one month without food for any reason, whether it's for improved cognition or weight loss or anything else (which was the thing I was commenting on) is dangerous and that opinion comes from seeing patients with unhealthy relationships with food going to extremes to lose weight.

 

[Styrene]

It's not lack of self control that keeps people from not going 36 hours without food. I'm a psychiatrist and I'm more than a little worried that doctors-to-be believe it's healthy to go one month without food.

Whether or not it's healthy depends on the person. But someone who is obese can survive one month without food with no brain damage.

 

[dr_kateb]

I’m confused here. Can’t you just eat a keto diet to maintain the ketosis without fasting?