Ket-OH-NO-sis

Eight Things You Ought to Know About the Ketogenic Diet

By: Katie Mark, MS, MPH, USAC, ALMOST RD! Essence Intern

Three years ago, I was obsessed with the ketogenic diet. I was in nutritional ketosis. I did it for weight loss and sport performance reasons.

In this blog, I will explain the basics of the ketogenic diet and then give you my honest eight things to consider before embarking into the world of keto.

What is the Ketogenic Diet?

The ketogenic diet (KD), or very-low carbohydrate ketogenic diet, is a diet high in fat (60-80% fat) and very low in carbohydrate (<10% carbohydrate). Based on clinical research, this is <50 grams of carbs per day, but can range between 20-50 grams depending on the individual. The KD is moderate in protein (which is relative because “moderate protein” hasn’t really been defined either).

This is NOT the same as a low carbohydrate diet. Even though there is no exact definition for what is “low carb,” it’s typically accepted as an intake of above 50 grams per day and up to ~150 grams. In this case, either protein or fat is higher. Traditionally, a “low carb” diet is usually higher in protein. But, “low carb” diet can be higher in fat, which is called a low-carb, high fat diet (LCHF) – this is still different from a KD because the person does not enter a state called nutritional ketosis (explained further below).

The concept behind the KD is that when you lower carbohydrate intake, this lowers your glucose (i.e., blood sugar) availability and shifts your body away from storing fat and instead, using fat efficiently as an energy source. The rationale behind the KD is that dietary carbs are not essential and are not needed for energy. The main fuel sources are fatty acids (provided by our fat stores or dietary fat) that are turned into ketone bodies, which are also created from dietary fat and fat stores. The brain typically prefers to burn glucose, but it adapts to using ketones for energy over time.

An important note about the KD is that there is a difference between nutritional ketosis (not dangerous) and diabetic ketoacidosis (dangerous – we see people vomiting in the ER and it’s potentially life-threatening!). Nutritional ketosis leads to ketone levels of 0.5 to 3.0 mmol/L whereas diabetic ketoacidosis leads to 10-20+ mmol/L.

What does the KD look like?
Fat: 70-75%
Protein: 15-20%
Carbs: 5-10%

For carbohydrate, this is approximately:
10-20 g veggies; or
5-15 g nuts/seeds; or
5-10 g fruits; or
5-10 g miscellaneous

The foods include:
High Amount: meat, eggs, butter, fish and heavy cream
Moderate Amount: low-carb veggies, salad dressings and cheese
Small Amount: nuts and seeds
Restricted: fruit, fruit juices, breads, grains, pasta, cereal, starchy veggies, high carb desserts and most dairy products

When it comes to treating obesity and cardiovascular disease (CVD), weight loss is usually recommended as a therapy. The KD is sometimes recommended. And some improvements in obesity and type 2 diabetes have been seen by using the KD. However, the impact of it on CVD risk factors is controversial. But the literature states that the KD may be associated with some improvements in CVD factors like obesity, type 2 diabetes and HDL cholesterol levels, but the effects are limited. So more studies are needed.

Also – it is NOT FUN to live like this! We know side effects occur, such as fatty liver, elevated cholesterol (which proponents say that it’s a different type of LDL cholesterol that is elevated – the fluffy type, not the small, dense LDL that is more likely to cause atherosclerosis, but discussing that is out of the scope of this blog!) and triglycerides, mental sluggishness, fatigue, hypoglycemia and fainting. The social repercussions are enormous. How can you go out to a birthday dinner and refuse all the dishes they serve?

Now that you are equipped with some information on KD (I encourage you to learn more, if you’d like, but be aware of who the sources are for that information), here are some concepts to keep in mind:

1. The Word “Diet”

The word “diet” is best to be phased out in the new era of nutrition. Nutrition is a science that is always evolving because research is always changing. (For example, we now know that low fat diets are not the best for our health. We do need fat, but the right type of fat).

“Diet” is defined as “to restrict oneself to small amounts or special kinds of food in order to lose weight.” The connotation of “diet” is something that is done for a short-period of time and is typically associated with a fad. Remember bell bottoms? Yeah. Fad.

However, if the goal is to lose weight or maintain your weight and have healthy levels of biomarkers (e.g., fasting blood sugar, cholesterol levels, etc.) then a “diet” is not the way to go. The better approach is to follow a healthful nutritional LIFESTYLE because to reach the aforementioned goals, that’s something you want to maintain the rest of your life. And that’s where diets, especially commercialized diets, go wrong because, yes, there is weight loss in the short-term, but studies find that people end up re-gaining that weight in the long-term. Why would they regain the weight? Because they didn’t continue with what they were doing while following the diet, which led to their weight loss in the first place.

This is why consistency and habit are key. If you stay consistent with the healthful eating patterns that help you reach the weight (or better yet, body composition, because weight is not necessarily an indicator of health status), that you desire then that is what makes the difference.

But what are “healthful eating patterns?” There are, of course, the basics of eating fruits and vegetables, whole grains, less processed food, etc. We are now realizing in nutrition research that personalized nutrition is gaining momentum. Therefore, investing in a Registered Dietitian (RD) is instrumental to helping you find what is healthful for you and will help you reach your health goals.

2. The Ketogenic Diet is Challenging to Sustain for the Long-Term

Going back to the KD, it is very challenging to sustain for the long-term. This brings us back to point #1. Eating meat, eggs and full-fat dairy for every meal and snack can only go so far. At what point will you get tired of it?

The other difficulty I had with the KD was the amount of cooking that was required. When you are a busy student or professional, it’s simply not realistic to be able to cook majority of your meals. Going out to eat becomes difficult because – what if your friends want to go to a pasta-heavy Italian restaurant? Going to parties or other social outings is also challenging because they revolve around food. It’s not always easy to find a ketogenic dietary option in those instances. This is not a diet where you can break it once – it’s very restrictive in order to stay in nutritional ketosis.

I’ll be honest. It gets boring. If you are a healthy person, what if you want to enjoy your grandma’s pie (that she only makes once per year) at Thanksgiving? There’s a dietary restriction that’s stopping you. You should be able to enjoy that food and not feel guilty. Also, this is a dietary restriction that was a choice – not required, unless you have a health condition that calls for the KD.

3. Why Do YOU Want to Follow the Ketogenic Diet?

This is a major point. I’ve been asked so much about it: “Should I do the ketogenic diet? I heard it helps you lose a lot of weight.”

So, I ask the client what they know.

“My trainer told me to do it.” “My friends do it and they lost weight.”

What I’ve found is that many people: 1) do not know what the KD is, but will blindly follow it; 2) have not done their own research; or 3) are doing it because someone else told them to or they saw someone else do it and that person saw benefits.

Most importantly, some people may think they are on the KD, but are they monitoring their ketone levels to make sure they are in a state of nutritional ketosis? Following this diet requires discipline in <50 g carbs. As previously mentioned, there are no “cheat” days. Blood ketone levels are ideal to measure, but keto sticks can be purchased to easily monitor urine ketone levels.

My best advice:
Define your goals.
Look into the research of the pros and cons of its effects on health and body composition.
Ask licensed nutritional professionals and health practitioners their opinions, especially in relation to your goals.
Seek advice from those who have done it, but keep in mind, what works for someone may not work for you because your genetics, goals, lifestyle, occupation and environment may differ.

4. Is It a High Protein Diet?

The KD is NOT a high protein diet. That is a big misconception. According to one of the leading keto researchers, Dr. Jeff Volek, this is a moderate protein diet consisting of 15-20% of your diet’s calories coming from protein or consuming only 1.0 – 1.5 grams of protein per kg of body weight per day. This is because a higher protein level may throw your body out of nutritional ketosis and/or lower the amount of fat in your diet.

This relatively lower amount of protein is important to keep in mind when attempting to lose weight by restricting calories. When you restrict calories, and protein is not at a “higher” level, precious, muscle mass is going to be lost first (and to a greater extent) than body fat. So if you worked really hard to build that muscle, it’s easier to lose and harder to regain. See point #7 below.

5. There is Probably A Reason Why Certain People are on the Ketogenic Diet

The KD was first created by researchers in the 1920s to stop seizures in children suffering from epilepsy. The diet is still used as a type of medical nutrition therapy today, but if other medications have not worked.

Polycystic ovarian syndrome (PCOS) is the most common endocrine disorder (experienced by ~4% of women) and is associated with central obesity, insulin resistance, high insulin levels, type 2 diabetes and abnormal lipid levels. There’s no cure. The KD has been used in a pilot study as a therapeutic dietary intervention with the goal to lower weight and improve insulin resistance. The KD did lead to significant weight loss and lower blood insulin levels (among other things) in women with obesity and PCOS. So it is promising.

The KD also holds promise as an effective medical nutrition therapy for improving the outcomes of traumatic brain injury (TBI) (commonly seen as the same as “concussions,” but not exactly the same). TBIs have different levels of severity. There have been indications that ketones may serve as another fuel source for the brain so that it does not have to depend on glucose metabolism as this may be impaired immediately after a TBI.

Interestingly, those in the military do experience concussions. Not by how we think of it (head-to-head collision), but via a bomb’s blast that causes an invisible concussive wave that radiates and damages the brain. Interestingly, I have spoken with a renowned Strength & Conditioning/Sport Performance coach who works with military snipers and has experienced a concussion from surfing. He found with himself and the snipers (through blood testing) that they all have a very difficult time managing their blood sugar. And they do not even follow a dietary pattern that would cause high blood sugar (showing diabetic levels). He and the other men have followed the KD and it helped them better manage their blood sugar. Ultimately, he stopped following the KD exactly because it was difficult to do as an athlete, but he does a modified form (more LCHF) and it has helped.

What is the underlying commonality in these situations for using the KD? There’s a specific therapeutic purpose.

There is also a group of relatively healthy people who use the KD to lose weight or manage weight, improve certain blood biomarkers, etc. If those people are on the KD and have been on it for a while – meaning they have accepted it as a LIFESTYLE, not a diet – and they are able to adhere to it and see the respective results then it could also mean it simply works for them. But the point is that what works for one person and their lifestyle and goals may not work for you, your lifestyle and your goals.

6. What Do Athletes Need to Know?

This is a much bigger discussion than this blog will do it justice. So I will be brief. For those familiar with sports nutrition, it is most definitely not a “one-size-fits all” approach. Even within an individual athlete, their nutritional lifestyle changes depending on what season they are in and their goals….and their life stage!

For some athletes, ketogenic is the way to go. This you will see more with ultra-endurance and endurance athletes. If you are training or competing for 2 to 24+ hours (obviously, depending on the sport), then it makes sense. They are preserving their carbohydrate stores and making EFFICIENT use of their fat stores.

This is where I ask the question: which is more important for that sport – the intensity at which you race or simply just finishing it (i.e., no time component)? If you are committed to being ketogenic for the performance purpose of running a 100 mile race (e.g., Leadville Trail 100 Run in Colorado) in which you are not trying to go very fast, but, rather, simply finish the race, then go ahead if you want.

If you compete in cycling time trials (in which speed/intensity is key), being ketogenic will not be the best option. However, it does NOT mean that you have to be a full-time high-carbohydrate athlete. This is why Nutrition Periodization™ is the better and a more accepted approach for athletes because it takes into different energy needs throughout an athlete’s training cycle.

Also, with respect to weight loss and body composition, this will depend. It may help during the off-season when you are trying to lose weight, but at what expense will it have on your muscle mass? Remember, the KD is NOT a high protein diet.

All of these considerations is why working with a sports RD can help you figure out what to do to help you perform at your best and reach your goals while maintaining good short- and long-term health.

7. The Ketogenic Diet Helps You Lose Weight! But What Type of Weight?

The KD may help you lose weight, but initial weight loss is most likely due to water weight. When you lower carbs so drastically, a lot of water goes with it. For every 1 gram of glycogen (i.e., carb storage), 3 – 4 grams of water are stored with it. So if you just stay ketogenic for a short “diet” then the weight loss will be short-lived once you go back to eating what you usually eat (which is higher in carbs).

Let’s consider the low fat versus low carb debate for weight loss. When it comes to weight loss, a major difference to look for between the two is: the amount of protein. If one study says the low carb group lost more weight and another study says the low fat group lost more weight, there’s obviously conflicting conclusions. But what was the protein amount for each?

During weight loss, muscle is one of the first things to go more so than body fat (shucks). Plenty of research shows that when it comes to weight loss and simultaneously NOT losing lean body mass (e.g., muscle), the amount of protein is the winner. When restricting calories, high protein amounts, especially combined with resistance exercise, result in more fat loss than muscle loss. Also known as – greater improvements in body composition (i.e., leaner).

This “higher” protein amount is 2-3x higher than the Recommended Daily Allowance (RDA) of 0.8 g protein per kg body weight per day. So 1.6 – 2.4 g/kg per day.

8. Carbs vs. Fat: The Debate

The KD and the Western Diet (typically high in carbohydrate) are on opposite ends of the carbohydrate spectrum.

But in all honesty, we should not go so low in carbohydrate and we should not be so high in carbohydrate. It should be CONTROLLED carbohydrate. The amount of carbohydrate is activity-dependent. If you are sedentary in a 9 – 5 PM job, 5 days per week, then going the higher carb route is neither the approach for weight management nor healthy biomarkers.

Obviously, controlling carb intake is difficult for many reasons – especially since carbs are addicting (e.g., sugar). So people have a tough time doing it – that’s probably why people want a yes or no (I can either have them or not) when it comes to carbs. When in actuality, you do need them, you just do not need a little and you do not need a lot (cue the Western Diet).

This is why a grey approach when it comes to carbohydrate is better. It is activity dependent and requires the selection of the right type of carbohydrate to help you feel full and energized. Therefore, working with an RD to personalize your intake based on your needs and goals will greatly help you.

Keto Or No?

Ultimately, science is now further supporting that nutrition is personalized (with, of course, basic healthy principles still applying). The KD is not a magic bullet – despite what is claimed by some in the fitness industry and media. For example, the KD may be a therapeutic option for people with certain conditions or it may actually help with weight loss in others. The best approach is to make sure you know what it is, the pros and cons of different parts of how it can impact your health, be honest with yourself as to whether or not you can follow it as a lifestyle (not a short-term diet) and speak with an RD or your healthcare practitioner about whether or not it’s right for you. If you do decide to do it, make sure to work with an RD who can help you make sure you are following it appropriately and monitoring the right biomarkers to keep you healthy!