Ketogenic Diets
In many videos and articles to which I have linked, you will often hear discussion of ketone bodies and/or ketogenic diets (very low carb, high fat, moderate protein). What is this “keto” diet, and is it safe, natural, or healthy?
It isn’t a specific diet, but a pattern of eating that could partially mimic fasting when in the high state of ketosis, basically lowering insulin enough to allow your body to break down dietary and/or stored fat to produce ketone bodies. While it won’t deliver the full benefits of a complete fast (water only), if applied correctly it can be quite effective and beneficial for addressing a number of metabolic and neurological issues. NOTE: a ketogenic diet is not necessarily a weight loss diet. Babies consuming only breastmilk are often on a type of ketogenic diet due to the high fat consumption, and they are neither losing fat nor muscle, but rather growing intensely and storing away necessary fat for future rapid growth spurts (nay-sayers see links below). The body is not stupid – during development, it will save up fat stores until it has enough energy for the next growth phase, then boom… the growth spurt occurs. Are babies in a high state of ketosis, probably not, but they are able to make use of multiple fuel sources rather than being restricted to just glucose. After all, what it the point of storing fat, if you are unable to use it effectively? Additionally, how in the hell do you think you are going to lose fat if you never get into at least low-level ketosis through diet or fasting? Whether or not you lose fat or not will depend on a number of factors such as total food consumption, eating window, reducing hyperinsulinemia and resulting changes to body set point (ref Dr. Fung), etc. If you stuff your face full of keto friendly foods throughout the entire day, then you are probably not going to lose any stored fat, but at least your insulin should come down some, so it’s still better than doing nothing.
Abstract – Neonatal ketosis is not rare https://www.ncbi.nlm.nih.gov/pubmed/11482735
Patterns of metabolic adaptation for preterm and term infants in the first neonatal week https://adc.bmj.com/content/archdischild/67/4_Spec_No/357.full.pdf
I could find more evidence, but this proves the point already.
If your goal is fat loss, then you will ultimately need to avoid over-eating so that you can begin to utilize your stored fat more than dietary fat. Fortunately, this type of diet can help diminish hunger by a number of pathways, so eating less on a ketogenic diet is often much more tolerated than on a high carb type diet. There are a variety of approaches from more meat/fat and dairy-based, a healthy mix, or even could be done vegetarian or dairy-free if necessary. For most people, this type of diet will improve metabolic markers of cardiovascular disease, but for a small percentage of people there is the possibility of increasing risk on some variations of the diet, so if you find yourself enjoying this lifestyle and sticking to this type of eating for multiple years, then it’s important to monitor important biomarkers such as LDL-p and CRP (really these biomarkers should be tested occasionally regardless of what particular diet you prescribe to, well homocysteine too, but that’s less related, and one single day’s values are not always going to represent your average, so don’t freak out for one single test. Repeat a few times, and if still bad, then start to take action). While many people respond well to this type of diet, due to genetic diversity and epigenetic expression, there are always going to be a few that struggle to switch over, and even a few that just don’t do well on this type of diet. A 3 to 7 day fast might be helpful to jumpstart the process if you are having trouble switching your body over to ketones and fatty acids. Myself, I switched over slowly for minimal side effects and had no issues, but some people have more trouble physiologically using ketones, or some just less patience.
As a spectrum, the diet could cause anywhere from intermittent and/or light ketosis, to moderate or more intense nutritional ketosis, but will never reach the dangerous condition of ketoacidosis provided that you are not a type 1 diabetic. By lowering carbohydrate consumption enough, while avoiding excessive protein, the body begins releasing fats for energy, some of which your liver processes into ketone bodies. While most people know that cells use glucose for energy production, they can also use fatty acids and ketone bodies as primary fuels to produce energy, and there are many benefits of doing so. Ketones must be metabolized aerobically in the mitochondria, and most anything that promotes cellular respiration is typically good for improving/sustaining mitochondrial health. While there are a lot of benefits to this, and it can be an effective treatment for certain conditions, it is not a requirement to always be in a state of ketosis to be on the road to a healthier you, and perhaps cycling in and out of ketosis might be a more natural and healthy pattern for many people.
Ketosis is not a cure-all, but there are a surprising number of conditions that can be improved with a higher state of ketosis. To me, this seems to suggest that rather than being some sort of magic diet, its more likely that it just resembles our natural state of being. Biochemical patterns that we were evolved/programmed to experience; bringing balance back a number of intertwined and interconnected systems.
For more info: Diet doctor has a lot of info in both English and Spanish
https://www.dietdoctor.com/low-carb – see this for who should NOT be doing keto without medical supervision.
https://www.dietdoctor.com/low-carb/ketosis
https://www.dietdoctor.com/es/keto
Peter Attia has a lot of info on his blog about ketosis (https://peterattiamd.com/), as well does Ben Bikman in his videos, Dominic D’Agostino is good for more advanced ketone topics and many interviews with discussion on the use of ketone supplements https://www.ketonutrition.org/
and Attia mentions Stephen Phinney as being other very good sources of info on this, but I haven’t followed up on that yet myself.
Also see https://www.ketogenic-diet-resource.com/ (as referenced by Dominic).
It’s pretty hard to avoid carbohydrates completely, so the level of ketosis will vary by how much you are able to avoid or lower your processed carbohydrate and starches, as well as limit protein intake on a daily basis. The amount of time spent in the fasted state will also play a big role as well. If your goal is to stay in a constant state of ketosis, then you will want to be very careful about your protein intake, and you might need to even limit some types of vegetables. Eating fat and fiber together with protein can help reduce the insulin spike that would otherwise occur due to the protein. Depending on how sensitive your body is or how severe your resistance, you may need to avoid fruits for a while until your resistance has improved. And when you do eat them, eat them whole (i.e. not blended or liquefied).
I personally think it unwise to take protein powders. Why? Because you need a lot more than just protein/amino acids – like minerals and micronutrients, fat, and fat-soluble vitamins, choline, essential fatty acids, etc. Maybe eat some real food if you need more protein? Lean protein is flavorless and awful for a reason, listen to your body, it wants all the fat and connective tissue also. Bones have a lot of nutrients that can leach out into the surrounding tissue or broth when cooking, so keep some of those in there as well. Organ meats are very nutritious as well if you are open to it. I personally haven’t been very adventurous on that front, but chicken wings have taken a spot on my favorites list with their high skin, fat, and connective tissue to meat ratio.
A low carbohydrate high fat (LCHF) diet is not necessarily a (constant) ketogenic diet, the level of ketosis will depend on a number of factors such as fat, protein, and carb ratios, as well as frequency of meals, total amount consumed, and daily fasting period. When you eat, insulin will rise up, and ketone production will decrease, spike insulin too high and it will drop ketone levels below the measurable range. The more that you condense your daily eating window and produce a long daily fasting period, the longer/higher you may be able to sustain significant ketone levels.
One thing I found interesting is it takes time for your body to be able to fully take advantage of ketones and fatty acids for energy usage – http://www.insuliniq.com/what-does-it-mean-to-be-fat-adapted/. So if you try to jump into a ketogenic diet quickly, you will probably feel a little drained in the beginning, mostly if you try to exercise, but after a few weeks energy levels should be getting back to normal or even better. If you are jumping into this very quickly, you may get a week or so of “keto flu”. Full ketone/fat adaptation is not a quick process. Many things are changing such as the ability to produce ketones, cellular ability to take in and utilize both ketones and fatty acids, as well as gut microbiome changes to adapt to HFLC type diet. While significant recovery and benefit can be noticed after a few weeks, Dominic mentions that different physiological and epigenetic changes continue for many months. Dom also mentions that in addition to being an energy source, ketones are signaling molecules affecting different systems in the body, and even have epigenetic effects.
A newer product on the market is ketone supplements (exogenous ketones like BOHB esters or salts). These are pretty expensive, especially the esters. They have shown some potential therapeutic value in the treatment of cancer, Alzheimer’s, and some other neurodegenerative diseases, but further research is needed to better understand pathways and effectiveness. Cost is another hurdle for most people, so making your own (internally) is probably the best route when possible. Medium-chain triglyceride (MCT) oil, virgin coconut oil, and MCT powders can also be taken to help give a bump in your ketone levels (a more modest bump, but for a much more affordable price). Although some GI issues may arise with the MTC oil, in which case the MTC powders may be preferred for some. However, the greater range of MCT types found in virgin coconut oil may provide other benefits that the MCT oils or powders do not (I will let you search for C8, C10, and C12 properties on your own). MCT vs VCO – a MCT oil will have a quicker and higher peak, whereas virgin coconut oil will see a lower elevation in ketones, but for a longer time period. Fasting is obviously a very effective way to boost ketone levels also. Taking exogenous ketones will reduce the amount that your body needs to create, meaning that you will burn LESS fat for a similar performance. This is fine in the treatment of Alzheimer’s or cancer, where your intent is not to lose weight. Just don’t think you will burn fat by taking ketone supplements (which is exactly what some ketone salts advertise). Taking ketone supplements might help jumpstart the adaptation phase, so in that sense could make it less painful to go hungry, but if your goal is to lose weight, then generally you want to utilize your fat stores to make your own. I also wonder if this shortcut would dampen the AMPK signaling response, and if so what consequences that would have? Meaning your body senses an energetic crisis, and in response upregulates a number of pathways to remedy the situation, including mitochondrial remodeling and biogenesis. Will ketones dampen this response, or will this adaption have to occur before the ketones can be fully utilized to improve the ATP ratios?
After experimenting with a few ketone salts, esters, and virgin coconut oils (VCO), I have taken a liking to a partially concentrated coconut oil made by Carrington Farms. I’m sure some other companies make some good ones, but this is just one I found at a local store and liked (however much cheaper online). Not a pure C8 MCT oil, but it’s much easier to swallow than the VCO, and has a good balance of C8, C10, and C12 (all of which have some beneficial properties). I notice a decent increase of mental energy, but at the fraction of the cost of a ketone salt. Note: if you are going to experiment with this, take one big spoonful at a time, maybe two. Taking more can result in a stomach ache for 20-30 minutes. I’ve taken up to 4 tablespoons at a time, sometimes getting away with it, and sometimes almost throwing up. And I didn’t really notice any extra benefit from taking more at once, so not worth the risk to me. Start off small, and increase over time as you get used to it. I also try to take it at least 45-60 minutes before exercise – again, minor stomach discomfort being the concern. I tend to get migraines when I fly or drive up into the mountains, but on the last few events I have had none while taking this the morning of. Maybe this is a key tool to avoid migraines when certain triggers are unavoidable, or maybe I just got lucky. I will keep trying it out to see if the pattern holds. (I’ve also recently been trying to address high homocysteine with a combination of supplements, so clearly I’m tweaking more than one factor at a time, making it harder to draw any conclusions. Not sure if the homocysteine has improved yet, I need to get it re-checked soon.)
https://www.amazon.com/Carrington-Farms-hydrogenated-unflavored-Packaging/dp/B072JNXCH6/ (actually is organic now – maybe they will update their site eventually). Note: I have no affiliation with this company and get no reimbursement, so click the link, search it out for yourself, or buy a different brand; it doesn’t affect me.
Testing for ketones – There are test strips that you can get for certain glucose monitors that can measure ketone levels in the blood. I prefer to keep track of both glucose and ketones (probably because I’m a little anal, but certainly there are some good reasons to do so). Nowadays I only test occasionally, except for when I am doing a longer fast, then I will check a few times per day.
https://www.dietdoctor.com/low-carb/keto/best-ketone-meter
https://www.myketokitchen.com/keto-resources/best-ketone-meters-monitor-ketosis/
The test strips are not cheap, so I went a long time before I finally got curious enough to buy one. They will most certainly be required if you are doing this for therapeutic reasons and need to confirm your ketone to glucose ratios. They may also be a worthwhile purchase if you are not sure if what you are doing is working or not, and just want to confirm if you are getting into nutritional ketosis. You may also notice more of a fruity smell to your sweat, so that could also be an indicator of some level of ketosis. Urine test strips are cheaper. Although they are not an accurate indicator of ketone levels in the blood, but could still be useful to know your approximate level of ketosis. There are some breath ketone meters now as well – said to be useful for indicating the general range, but not able to give accurate values at this point; hopefully they will get there soon.
Ketone meters may be able to tell you if you are in a state of ketosis, but knowing to what extent is quite a bit more complicated and not very clear. First off, early morning is not a good time to measure either ketone or glucose levels. This is due to the dawn phenomenon causing higher glucose and lower ketone levels than the rest of the day, even when fasting https://www.dietdoctor.com/the-dawn-phenomenon https://www.dietdoctor.com/low-carb/fasting-blood-glucose-higher.
Also, if you are already fat/ketone adapted, then your body is more efficient at using ketones and fatty acids for fuel. In this case, you may not see ketone levels get as high because you use them as quick as you are making them, so they do not continue accumulating in the blood. This is a good thing, but if you are not aware of this, it could be a little discouraging by causing you to think that you are barely in ketosis, when in reality you may just be a good ketone user. On the flip side, someone could be getting high ketone levels, but if not yet keto-adapted or they have some genetic variation resulting in the physical inability to use ketones readily, then they may not be able to make good use of them. Probably paying attention to how you feel regarding energy levels, mental acuteness, and hunger is a better measure of how well you are producing and using ketones.
https://www.dietdoctor.com/low-carb/fasting-blood-glucose-higher. Also, if you are already fat/ketone adapted, then your body is more efficient at using ketones and fatty acids for fuel. In this case, you may not see ketone levels get as high because you use them as quick as you are making them, so they do not continue accumulating in the blood. This is a good thing, but if you are not aware of this, it could be a little discouraging by causing you to think that you are barely in ketosis, when in reality you may just be a good ketone user. On the flip side, someone could be getting high ketone levels, but if not yet keto-adapted or they have some genetic variation resulting in the physical inability to use ketones readily, then they may not be able to make good use of them. Probably paying attention to how you feel regarding energy levels, mental acuteness, and hunger is a better measure of how well you are producing and using ketones.
Ketogenic diets have been used for about 100 years as an effective treatment for epilepsy not responding to medications. They have also been found to be an important component in metabolic cancer treatment, as well as useful for some migraine reduction, reducing autism symptoms, delaying Alzheimer’s or improving severity, and other neurodegenerative diseases. The classical therapeutic diet would be very high fat (90% of calories). This is pretty extreme, and not required for general health and fat-loss purposes, and may be more difficult to adhere to long term (this would be quite difficult to achieve dairy-free). A modified keto diet generally allows for more protein and low-sugar/non-starchy fruits and vegetables (my favorites are sweet peppers, avocados, and broccoli). While you may not get quite as strong of an effect with the higher protein, if you wanted to further boost ketones, you could add time-restricted eating to help ramp up ketone levels during the longer fasting period (aim for 6hr or less eating period per day for maximum effects).
I personally don’t keep track of calories, carbs from non-starchy veggies, fats, protein, etc. (with the exception of very roughly counting grams of added sugar per day). I’ve never really tried to track them; it just seems like too much a pain in the ass, and impossible to do accurately, so I just don’t. So for me, time-restricted eating plus low carb works to keep me in a low state of ketosis for much of the day. I know that if I eat my massive lunch (see photo for my typical weekday), that all the protein will probably bump me out of ketosis for a short while, but not nearly as long as if I hadn’t been fasting for the last 16-18 hours. Plus most days I only shove my face that full once, and then it’s often a smaller dinner. Occasionally (i.e. maybe once per week) I may have a donut to finish it off, and then I know that retaining consciousness will be near impossible. Not advisable, but old addictions die hard. Unfortunately, they just don’t taste anywhere near as good as I remember, so I mostly just stick to dark chocolate these days.
While the majority of people will see an improvement in cardiovascular disease risk, Attia and others talk of a small but significant (maybe up to 20%) of people who respond differently to an extremely high-fat diet in regards to LDL- particle numbers and inflammation. Does elevated LDL-P with low oxidative stress, inflammation, and low insulin still contribute to cardiovascular disease? I would think that it could still be concerning, because all of the three required factors (particle number, inflammation, ox stress) are never zero, even in an individual with the best markers, there will always be some low level of arterial damage. Hopefully at a rate low enough that the body is able to clean and repair most of it, but nonetheless it is occurring. Because none of these three factors could really be considered rate-limiting, it stands to reason that raising any of them will increase the rate of damage incurred. Thereby, even with low oxidative stress and low inflammation, a high LDL-p will likely have a higher rate of damage compared to when all three are low. Are they still lower risk than before they started the diet? Possibly, but even if true, that doesn’t mean they couldn’t improve their risk further by trying to tweak their diet and drop down the LDL-p.
The reason for this LDL-P spike is not well understood. Maybe it could have something to do with gut health or poor microbiome diversity? Or possibly if a food allergy or mild intolerance to something like wheat, dairy, etc. is causing intestinal permeability, that will lead to inflammation. Also, if the only forms of carbs that you are eating is sugar, soda, or donuts, rather than veggies and fruits, that might not be so good for your insulin levels or your gut. Or maybe this is due to something else entirely, like sleep, stress/cortisol, micronutrient deficiency, etc. Dr. Attia says he has found that tweaking the fat composition (increasing monounsaturated fats and reducing saturated fats) has worked out well with many patients, with the possibility that a genetic polymorphism related to fat metabolism might be to blame for some individuals. Whereas Dom mentions that he himself had to reduce (but not eliminate) dairy proteins and increase coconut and other oils to reduce his LDL-p, so it’s possible that this is more of a response to a specific fatty acid type/length or protein found in dairy for some individuals. As occurs frequently in the field of medicine, there are often multiple causes/pathways/dysfunctions that yield a similar phenotype; what works well for some, may have no effect for others with the same symptoms but different root problem.
It also stands to reason that someone could follow a keto-type diet, but if they eat frequently for most of the day, they may end up missing any improvement or progress towards their goals. The lack of the fasted state is likely a major contributor towards our current health crisis.
In summary, ketogenic diets are a useful tool for lowering insulin resistance, glucose control, neurological health, and many other things, but for maximum health, some individuals may need to be a little more careful in their approach. Effective health screening, like advanced lipid profiles(LDL-P), hrCRP, etc., should be able to signal that there may be some adverse effects, but at least from my own personal experience most physicians don’t run these tests as part of any routine screening, so those may need to be specifically requested, and may need to be paid for out of pocket. If you do see some of these numbers go in the wrong direction, you don’t have to just quit. Recheck in a couple of months to verify that it wasn’t just a transient effect, and if they are still off, then try tweaking the sources of fat that you are consuming. Cardiovascular disease doesn’t develop overnight, often developing over decades of exposure, so don’t get too stressed that things are off for a few months, but don’t let it go indefinitely either.
If you are doing this for fat loss, then it’s critical to keep in mind that this is not an all you can eat keto buffet. Keeping your insulin low will help avoid gaining weight, but if you eat more than you need to run your metabolic processes, then you won’t lose any fat either. As you turn down insulin, your hunger should become less intense. Don’t just eat out of habit, but rather listen to your body and eat less often (and/or smaller portions).
