Ketogenic Diets

Most people begin with moderate carbohydrate restriction, but this may not be enough for them to reach their goals. They must restrict carbohydrates even further, in order to reduce blood glucose dysregulation, so they decide to try a ketogenic diet instead. But, what is a ketogenic diet and what's the difference?

 
The purpose of ketogenic diets is to be in a state of ketosis. Ketosis is a normal metabolic process, where your body mostly burns fat, for fuel, instead of glucose. The byproduct of burning fat are ketone bodies. Ketogenic diets can be used as an intervention for the treatment of many diseases:

• For the treatment of neurodegenerative disease, seizures or cancer, the consistent production of ketone bodies is the goal.
• For the treatment of metabolic diseases, the burning of fatty acids is the goal.

For metabolic treatments, the only difference between common carbohydrate restriction and a ketogenic diet is the degree of carbohydrate restriction, because all carbohydrate restriction results in periods of ketosis. Ketogenic diets are just very low carbohydrate diets, allowing for more periods of ketosis.

A ketogenic diet is any diet that is:

• Very low in carbohydrate.
• Moderate in protein, enough to sustain your lean body mass.
• High in fat, where most of your calories come from. For the treatment of seizures and other diseases, this fat comes primarily from diet and/or ketone esters. For the treatment of metabolic disease, this fat comes primarily from body fat.

In total daily calories, the percentages would look like this:

• Carbohydrates make up 10% or less, protein makes up 20% and the rest is fat.

Overview

• Classic, therapeutic, ketogenic diets, used for the treatment of neurodegeneration, seizures or cancer, are very high in dietary fat and restrict protein, because to treat these conditions, there must be a sustained presence of ketone bodies. For these diets, dietary fat is essential. These diets require carbohydrates to be less than 20 grams a day and in some cases, even lower. Adults aim for 0.8 grams of protein, a day, per kilogram of actual body weight. These diets use, no less, than a 4:1 ratio between fat and the other macronutrients. This equates to 4 grams of fat for every 1 gram of protein and carbohydrate, combined. Because this diet is so high in dietary fat and so low in protein, supervision by a doctor and dietician is required for the tracking of calories in order to prevent weight gain or loss, and the tracking of protein to ensure that lean muscle mass is being preserved. Supervision also ensures there aren’t any nutritional deficiencies or other complications occurring.
• Ketogenic diets used for the treatment of metabolic diseases do not need a sustained presence of ketone bodies, because ketone bodies do not affect weight loss or metabolic health. For these diets the burning of body fat is essential. Carbohydrates should be kept between 30 - 70 grams a day, depending on the state of insulin resistance. Individuals who are diabetic, are advised to keep carbohydrates no higher than 30 grams a day. Adults aim for, no less, than 1.2 – 2.0 grams of protein, a day, per kilogram of desired body weight. This diet, usually, does not track calories and fat is “eaten to satiety”, however, it is a known fact that people who suffer from metabolic syndrome/diabetes have trouble with satiety signaling, especially from energy macronutrients, so for this reason, recommended limits for fat intake are - for weight loss a maximum of 60 - 100 grams of fat a day and for maintenance 100 - 200 grams of fat a day. If the person is still having trouble losing weight or managing their macronutrients, then calorie tracking is required.

If you are reading this blog, then you are most likely considering a ketogenic diet for the improvement of metabolic health. I will only be discussing ketogenic protocols in the context of improving metabolism. If you are looking to follow a classic ketogenic approach for the treatment of any other disease, you must have it formulated and monitored by a healthcare professional. Classic ketogenic protocols are not discussed on this blog. 

The Basics

Ketogenic diets starve the body of glucose and force it to use fatty acids, as a primary fuel source. The byproducts of fatty acid metabolism are called ketones. Ketones primarily help fuel the brain, when glucose is scarce, while the rest of the body mainly utilizes fatty acids. In this regard, you can say that the diet's goal is to increase the body's catabolic state. This is achieved by maintaining fasting insulin at low levels, through the strict regulation of blood glucose. The premise is that, if the diet is properly formulated, it will cause leptin to allow stored body fat to be released from fat cells, and dietary fat to not be excessively stored by insulin.

Because of the very low carbohydrate allowance, the diet is different than a standard carbohydrate restricted diet, which allows carbohydrates to go up to 50 grams, a day, and in some cases 100 grams. Standard carbohydrate restricted diets also, do not require macronutrient ratios or calculation of protein.

The reason that the diet focuses on protein as well as carbohydrates is because of proteins affect on ketone production. A lot of people believe that ketone production seizes, when protein is consumed, because extra protein gets converted to glucose, in the liver, through the process of gluconeogenesis. But, gluconeogenesis is a tightly regulated and demand driven process that occurs all of the time. Rather, protein is a unique macronutrient. It is the only one that can temporarily halt fat burning, without increasing glucose burning. Protein can increase insulin, just enough, to suppress free fatty acids and therefore temporarily halt ketone production. This is an affect that can be problematic with people who require to be in ketosis.

The Risks

This is not a simple "weight loss" diet. It is a diet that is switching your metabolism from primarily burning glucose, to primarily burning fat, so it can be best described as a metabolic therapy. For metabolic health, achieving a state of mild to moderate ketosis can be beneficial, but because of its profound effect, there are some risks.

If you are relatively healthy, the only risk associated with this diet is electrolyte depletion and imbalance. You must track your electrolyte intake very carefully. Failure to do so, cannot only cause unpleasant symptoms and discomfort, but it can result in irreversible, adverse health consequences and even a visit to the emergency room. You should view this electrolyte guide for recommendations.

Metabolic interventions can cause adverse effects for people who have a pre-existing medical condition like type II diabetes. Because diabetics have such high insulin, if they drastically reduce dietary carbohydrates, their blood sugar can drop to dangerously low levels. This is especially true for insulin dependent diabetics or those currently on diabetes medications. 

People who are on diuretics or have kidney disease, also should be extra cautious, because the lowering of insulin causes a release of retained water and this in turn can create a higher risk of serious electrolyte imbalance and dehydration.

If you are on any medications or have any pre-existing medical condition, first consult with your professional health care provider before starting a ketogenic style diet or any form of carbohydrate restriction.

Is It for Everyone?

This is an intensive diet that requires a lifestyle and mindset change. Regardless of what you may have read on the internet, you're not going to eat butter and magically become a fat burner. It doesn't work that way, and it gives inexperienced people a false impression of what to expect. The correct implementation of the diet is vital for its success. It is not an “all you can eat, as long as it’s fat” diet. This is not a fad or crash diet. You must be committed, as adherence must be consistent for the diet to be beneficial and avoid negative outcomes.

Every single last one of us, has a metabolism that evolved to be able to go into ketosis, for the mobilization of fatty acids and production of ketone bodies. This enabled us to survive during periods of starvation. Ketosis is the body's reaction to starvation, but it’s not negative. You go into ketosis every night and your brain uses ketones, while you sleep. But, there are still some exceptions. Children, nursing or pregnant women or any one with a pre-existing condition or on medications, must consult with their healthcare professional before implementing any new dietary regimen, including this one. You can get the most out of your dietary protocol, when your doctor is involved.

Ketone Testing

How do you know if you are in a state of ketosis? Easily. You are losing body fat. As long as fat is being lost, you are in periodic states of ketosis.

But, there are several products out on the market that help you test for the presence of ketones. These include ketone urine test strips, ketone breathalyzers and blood ketone meters. These gadgets work differently and there is a lot of debate on what they are measuring and what those measurements mean, but they all do have one thing in common: they are unnecessary. You're not required to test ketones when following a ketogenic diet for better metabolic health and weight loss.

People that are following a ketogenic diet for the treatment of seizure disorders, cancer or other serious medical conditions, would be under medical supervision and their doctor would be performing the ketone testing for them.

Why is it unnecessary to track? Because having the presence of ketones in your urine, breath or blood tells you nothing about whether you are burning body fat or not and the burning of body fat is the goal for the improvement of metabolic health. The presence of ketones simply means that you can produce them. You can, absolutely, remain obese, gain weight and continue having metabolic dysfunction, regardless of ketone levels. The purpose of ketosis is to be healthier. That is the goal. The goal is not to see how high your ketone numbers can get, while remaining obese and/or sick.

If something truly works, then we would be able to see the results. If you're losing weight, feeling healthy, having energy and having improved metabolic markers, then your ketogenic diet is working for you. How many ketones you have is irrelevant to these improvements.

The only ones who want you to test for ketones, are the ones selling ketone meters, but ketosis is free.

Exogenous Ketones

People that need to follow a classic ketogenic diet, for the treatment of serious medical conditions like cancer, neurodegenerative disorders and/or seizures are often given exogenous ketones, under the supervision of medical professionals. These exogenous ketones are often required for their medical care, as diet, alone, cannot produce adequate or consistent ketone levels needed for their treatment.

But, when following a ketogenic diet for better metabolic health and weight loss, you want your body to produce its own ketones from burning stored body fat. This is what ensures you are losing weight and improving metabolism. So, stay away from exogenous ketones. They are expensive, and they do not guarantee that your body will use them efficiently, any more so than the ones produced by your own body for free.

The only ones who want you to take exogenous ketones, are the ones selling them, but ketones are free.

Ketogenic Products

The best thing about ketogenic diets is the same as with fasting - it’s free! There is nothing to buy. No special gadget is needed.

 
The diet is based on real food. But, just like the low-fat diet was used to create a slew of heavily processed, Franken junk foods, with the "low fat" sticker on them to ease our fears, ketogenic diets have not been immune to this kind of exploitation either.

Eating whole foods is what will ensure you're getting all your macro and micronutrients, in the right ratios. This is what’s most recognizable and beneficial for the body. So, no matter what anyone out there tells you, there is no such thing as a "keto snack". The only "keto snack" that exists is body fat. People on ketogenic diets, do not snack. You don't need "keto" supplements, "keto" bars, "keto" drinks, "keto" powders or anything else with the "keto" label on it. If it has a label, any label, then by default, it is not “keto”.

The only ones who say you need ketogenic products, are the ones selling them, but ketosis is free.

"Fat Adaptation"

When you first start a ketogenic diet, you will lack sufficient enzymes that help break down fats and utilize ketones. This is a temporary inefficiency, as the body soon builds them up.

Aside from that, the body does not need to adapt to anything, it only needs access. Our bodies are hybrids. We do not burn only glucose or only fat. We burn both. What’s important is which fuel is burned primarily.

When you are following a ketogenic diet for the improvement of metabolism, you want to burn primarily fat, but not just any fat. You want to burn stored body fat. To gain access to this fat, you must lower insulin levels and normalize its function. The premise is that once your insulin levels are low enough and its function is improved, then leptin will allow stored body fat to be accessed and burned. This will prevent you from being hungry between meals, feel fatigue, tired and/or lethargic. You also will not experience the effects of “hypoglycemia”, such as dizziness and headaches. These symptoms are not caused from "fat maladaptation", they are caused by blood glucose dysregulation which affects insulin levels and function. This does not allow you to access your fuel stores and keeps you dependent on dietary fuel only.

Though you want your body to burn fat primarily, you also want it to burn glucose secondarily and be efficient at it. This is called metabolic flexibility. Though you are not intaking glucose from your diet, your body makes glucose through various processes and you want it to burn this glucose, not store it again. This is done by achieving and preserving insulin sensitivity which allows glycogen synthesis and the building of lean body mass.

Macronutrient Counting

There are many free apps where you can log your food and get a visual of what your macronutrients are, but some people need a much stricter method of keeping track of what they eat. Below are some options.

Basic Ketogenic Macronutrient Example:

• Induction - 80 - 120 grams of protein, 30 - 50 grams of carb, 60 - 100 grams of fat, a day.
• Maintenance - 80 - 120 grams of protein, 30 - 70 grams of carb, 100 - 200 grams of fat, a day

If you prefer to have a more personalized macronutrient guide, I recommend the Ketogains Calculator. If you do not have access to a body fat scale, you can get a rough estimate of your body fat percentage using the US Navy Body Fat Calculator. You can also use the visual chart found here.

Some people may also need to measure and/or weigh their food and still others must track caloric intake, as well. What you choose to track and how closely, is up to you and your personal comfort. For some, goals cannot be reached unless diligent tracking is done, but for others, that's not the case.

An additional method of tracking intake and controlling macronutrients is time restricted eating/intermittent fasting. Having no more than two meals a day, with no snacking in between, helps track your food consumption and satiety signals.

How To Get Started

The best way to go ketogenic is to do it in stages.

1. Get rid of sugar and grains first, but keep starches in the form of squashes and tubers, as training wheels. Use these carbohydrates to help ease a change in metabolism, but remember that these training wheels will eventually have to come off.
2. Stop all the snacking. Only eat at meal times and limit your meals to three, then two. This will give you a 16 - 18-hour, water only fasting, period daily. This will allow your body to begin tapping into its fat stores for fuel.
3. Finally, remove all starches and replace them with above ground vegetables only.

Ketogenic diets will make your fasting protocol easier to follow and will give your metabolism the flexibility to use fuel from your own body fat, primarily, and your own blood glucose, when needed. This will allow you to no longer be a slave to exogenous sugar and continuous eating.

What Can Go Wrong?

Aside from neglecting electrolytes, other problems can arise from going ketogenic. Usually, when problems arise, it’s because the diet is not well formulated. The most common mistake that can lead to problems is when people apply classic ketogenic principals to their diet.

• Extreme restriction of protein - Protein is the master macronutrient. It induces satiety; it’s one of the main regulators of the insulin/glucagon interaction, preventing a chronic catabolic/anabolic state; it preserves and builds lean muscle mass; it’s essential and the foods that contain it are high in micronutrients and low in energy. If protein consumption is too low for too long, you will have multiple adverse health consequences, including metabolic damage. 
• Eating fat ad libitum, a.k.a “to satiety” - Obesity is not just a by product of insulin resistance. It is the consequence of leptin resistance. When you are leptin resistant, the body does not signal satiety, from consuming fat, and metabolism is not increased in response to it. This causes for an enormous amount of fat to be eaten in the futile search for “satiety” and it is all going into storage. Pure fat has a minimal effect on bolus (after meals) insulin levels. But, it does influence basal (fasting) insulin levels. This is because insulin is not required to metabolize fat, but it is required to store it. If you eat excess fat, it will be stored, and you will get fatter, as leptin is not burning it. Therefore, classic ketogenic diets, for therapeutic purposes, are calorie restricted. In ketosis, used for better metabolic health, fat should be eaten with its accompanying protein, in whole forms only. It should never be eaten in a concentrated and/or isolated form and certainly not in excess.
• Chasing ketones - Eating large amounts of fat will produce more ketones, but ketones are regulated by insulin, in a negative feedback loop, to prevent ketoacidosis. If excess fat is eaten, whatever is not burned, will be put right back into storage, regardless of ketone levels. Therefore, you can still get fat, while in ketosis, and why the diet has also been used for weight gain. The fatter you become, the more insulin demand you will have, as the body tries to hold back this fat in storage.

Common Side Effects

"Keto" Flu - The "keto flu" is a temporary condition that usually occurs when the person first goes on a ketogenic diet, but can also happen later, as weight decreases. "Keto" flu can cause fatigue, headache, irritability, difficulty focusing, lack of motivation, dizziness and nausea. Many people think this is caused by a "withdrawal from carbs", but it's not. Your body makes its own glucose, so you are technically still on carbs and will forever be on them. The body uses both glucose and fats and knows how to use both, very well, so there is no such thing as "withdrawal". 

The "keto" flu is usually the result of an electrolyte imbalance. As insulin levels lower, the kidneys respond by releasing large amounts of water, which deplete electrolytes. The severity of this condition, and whether you will even have it, is individualized as we all lose electrolytes at different rates. The more weight you have on your body, the less risk of this effect. This is why I always stress the importance of electrolytes. If your "keto" flu is being caused by an electrolyte imbalance, you must address it as it can become serious. It will also not resolve itself and you will suffer needlessly. Oftentimes, this is the very reason many people stop their diet.

Another, less common, cause of the "keto" flu is the presence of ketones themselves. Ketosis is a mild form of ketoacidosis, which is not harmful when it is controlled by insulin. As long as you can produce insulin, this ketoacidosis does not become dangerous. But, when the body first begins producing ketones it can temporarily react adversely. This is because ketone bodies are composed of acetone, acetoacetate and beta-hydroxybutyrate, which are all toxic, acidic chemicals. These toxic chemicals are actually beneficial and useful, when the body can properly control them.

This adverse reaction to ketones is temporary. As insulin mitigates ketone levels, and enzymes build up to break them down, reducing them, it should pass.

Keto Rash - A "keto rash" is a mildly itchy rash that can appear on any part of the body, but usually affects the upper torso. Many people believe this is caused by "allergies" to new ketogenic foods or bacterial dysbiosis from lack of starch, but it's not. 

The "keto" rash is a type of dermatitis caused by ketones themselves, which are present in urine and sweat. Remember, ketone bodies contain acidic compounds, which are irritating to the body. The acetone in ketones is the main culprit of this rash and some people are just more sensitive to it than others. This irritation to ketones can be compounded by other irritants like heat, friction, lotions and perfumes. Many people never get a "keto" rash, at all, even though they are in ketosis.

"Keto" rash usually resolves itself. Try to avoid over exposure to heat, wear looser clothing and change it daily, limit the use of harsh lotions and perfumes, shower immediately after exercise or sweating and keep your skin dry and clean. Applying cornstarch based baby powder (do not use talc) on the areas where the rash appears, can help absorb any sweat that can build up ketone bodies on the surface of the skin.

Some people find the application of apple cider vinegar beneficial, but apple cider vinegar is also acidic. The perceived benefit is most likely due to the removal of the ketones, when you wipe the rash with vinegar. You can try it and see if it works for you, but the best way to stop the rash, is to not let ketones build up on the skin.

Smelly breath, sweat and urine - Ketone bodies are made of acidic compounds, which include acetone (nail polish remover/paint thinner). They are released in the breath, sweat and urine, so they can make them all smell like acetone. This is temporary and as insulin mitigates ketone levels, by reducing them, this effect should disappear.

Urinary infections - Ketosis in people with no insulin, like type I diabetics, is usually accompanied by very high blood glucose. This is ketoacidosis, which is dangerous as the acidity in the body builds up to deadly levels that damage organs. The kidneys try to eliminate both the ketones and blood glucose through urination. It's this large amount of excess glucose, which causes the urinary tract infection, not the ketones.

Just because you are experiencing "flu" like symptoms, a rash or any other ailment, does not mean that it's related to your diet. There can be many other reasons for your symptoms. For this reason, if you are experiencing any unusual symptoms, which persist or get worse, contact your healthcare provider.

But Will It Work To Reverse Obesity? 

Ketogenic diets work like every other diet so they have the potential to fail. The only difference is that ketogenic protocols give you a metabolic advantage by addressing the root cause of metabolic syndrome - blood glucose dysregulation. 

Because the diet is so low in carbohydrate, the risk of blood glucose dysregulation goes dramatically down but not away. Other things affect blood glucose regulation besides diet. Medications, chronic conditions and the exaggerated stress response of people with metabolic syndrome, all contribute to blood glucose dysregulation. As long as this dysregulation persists, metabolic abnormalities will remain. As long as metabolic abnormalities remain, obesity progresses.

The main things that people with metabolic syndrome have to be wary of when it comes to ketogenic protocols are:

• Chronic ketosis - The presence of ketones is a strong indicator to the body that it is starving. This can cause a doubling down of leptin under expression keeping you obese. For this reason, it is better for some to be in ketosis periodically, not chronically. This can be achieved with a low carbohydrate protocol.

• Inadequate protein - Protein is the antidote to starvation so if you restrict it, you will once again double down leptin under expression. Low protein also causes more muscle mass depletion, increasing your fat mass by proxy.

• Excessive dietary fat - No leptin = no fat loss. So if you aren't burning any body fat but continue intaking large amounts of dietary fat, you are only becoming more obese over time.