Low Carb Ketogenic Diet

Learn how a whole-food low carb ketogenic diet can be formulated to treat and reverse diabetes and other associated metabolic conditions. This is a satisfying part of a sustainable lifestyle that can help you regain your health starting today. The low carb ketogenic diet using whole-foods is the most powerful of the lifestyle changes to naturally prevent or treat diabetes and achieve excellent blood sugar control. The combination of near-normal blood sugars, normalized insulin sensitivity and normal insulin levels can prevent or reverse many diabetic complications and minimize hypoglycemia (low blood sugars). In addition to the low carb ketogenic diet, additional lifestyle changes can help improve your diabetes and prevent or treat many associated metabolic conditions. You can explore them in the Navigation Bar above.

Conditions Benefited By A Low Carb Ketogenic Diet

All of the medical conditions listed below have one thing in common: DIETARY CARBOHYDRATE INTOLERANCE. These conditions are also characterized by insulin and often leptin resistance with varying degrees of hyperinsulinemia (elevated blood levels of insulin).

Here is a list of conditions that can be treated by and I expect also prevented by following a well-formulated, whole-food, low carb ketogenic diet.

  1. Insulin Resistance
  2. Glucose Intolerance or Prediabetes
  3. Type 2 Diabetes
  4. Type 3 Diabetes (Alzheimer's Disease)
  5. Metabolic Syndrome
  6. Abnormal Cholesterol or Triglycerides
  7. High Blood Pressure or Hypertension
  8. Non-Alcoholic Fatty Liver Disease
  9. Obesity, Overweight, Abdominal Obesity (Visceral Obesity)

For important background information about the Western Diet which has lead to the current epidemic of insulin resistance, obesity, diabetes, and many related metabolic diseases, please read my Low Carb Diabetes Diet page.

Who Should NOT use a Ketogenic Diet

The following medical conditions are usually diagnosed in childhood (except porphyria can be diagnosed later in life) and most people who have these conditions are already aware of them. However, you should be aware that these conditions exist and represent absolute contraindications to the use of a ketogenic diet. This list is taken from Eric H. Kossoff, MD's book Ketogenic Diets, Treatments for Epilepsy and Other Disorders. This is an excellent book that I recommend for anyone with epilepsy.

  1. Carnitine deficiency (primary)
  2. Carnitine palmitoyltransferase I or II deficiency
  3. Carnitine translocase deficiency
  4. Medium-chain acyl dehydrogenase deficiency
  5. Short-chain acyl dehydrogenase deficiency
  6. Long-chain acyl dehydrogenase deficiency
  7. Long-chain 3-hydroxyacyl-CoA deficiency 
  8. Medium-chain 3-hydroxyacyl-CoA deficiency
  9. Mitochondrial HMG-CoA synthase deficiency
  10. Pyruvate carboxylase deficiency
  11. Porphyria

This section gives me another opportunity to say that anyone with medical conditions and/or takes one or more medications should involve their physician in their decision to adopt a low carb ketogenic diet. This is for your safety, after all this is the main reason for making a lifestyle change: to improve your health. There is no sense in risking your health in the event you have an unusual medical condition, an unusual reaction to the diet, or you do not implement it correctly.

The Low Carb Ketogenic Diet

A whole-food low carb ketogenic diet is generally defined as one that

  • is devoid of processed foods.
  • generally contains less than 50 grams/day of total dietary carbohydrate for the majority of individuals.
  • contains 1.2 - 2.2 grams protein/kg/day. 
  • contains the balance of calories in healthy fats to achieve a lean body composition.
  • healthy fats generally come with animal protein foods e.g. eggs, beef, lamb, pork, dark-meat chicken, organ meat (offal), fish.
  • added healthy fats include butter, cream, cheese, coconut, palm, and olive oils, but will slow fat loss and resolution of insulin resistance in those with excess body fat.
  • results in nutritional ketosis: a natural adaptation to dietary carbohydrate restriction. Nutritional ketosis may have some unique benefits, but it is difficult to make broad claims due to lack of long-term studies of numerous study subjects. Due to fact that it is difficult for a commercial venture to profit from nutritional ketosis, there is not much incentive to perform the needed studies. Virta Health has embarked on a 5-year study of nutritional ketosis in persons with prediabetes or type 2 diabetes. Lack of studies has not dissuaded me from enjoying the many benefits of a low carb ketogenic diet for diabetes.
  • Because nutritional ketosis defines a ketogenic diet, the amount of dietary carbohydrate that can be tolerated varies from about 20 grams/day in very insulin resistant individuals to 100 - 150 grams/day in very athletic individuals.

These foods are nutrient-dense and naturally low in carbohydrates:

  1. Beef, Lamb, Dark-Meat Chicken, Fish, Eggs, and other animal products including organs (liver, heart, kidney, offal).
  2. Non-starchy vegetables - leafy greens like Brussels sprouts, kale, collard greens, cabbage, spinach, yellow squash, zucchini, eggplant, tomatoes (all cooked, raw, or fermented), raw carrots, and many others.
  3. Nuts & Seeds - Pepitas, macadamia, pecan, Brazil, walnuts, cashews, pistachios, almonds, others.
  4. Low Carb Fruits (frequency and quantity limited depending on one's metabolic response) - Avocados, olives, blackberries, raspberries, blueberries, others.

These drinks are naturally free of sugar which is important:

  1. Plain water, filtered water, reverse osmosis water.
  2. Unsweetened Tea or Coffee
  3. Does not include drinks with artificial sweeteners. Here's why.
Ketogenic Breakfast - cooked pork sausage, cauliflower, carrots, Brussels sprouts, unsweetened coffee.

How Much Carb Restriction Is Needed?

As mentioned above, the general rule for carbohydrate restriction on a ketogenic diet is < 50 grams/day of total carbohydrate (includes fiber). This cut off was selected because the majority of persons restricting dietary carbohydrate to this degree will achieve nutritional ketosis (NK). However, individuals are, well, individual so the actual number varies and you can determine this for yourself. In general, the degree of carb restriction needed to achieve NK depends on the degree of insulin resistance. Very insulin resistant individuals may need 20 grams/day or less carb restriction to achieve NK. As mentioned above, very athletic individuals may be able to eat 100 - 150 grams/day and say in NK. This simply demonstrates the insulin sensitizing effect of exercise and why I believe it is an important part of lifestyle change for metabolic disorders like diabetes. It is true that the more restrictive the carb intake is, the fewer foods options you have. Personally I have found that the longer I continue my ketogenic diet, the less desire I have for foods containing carbohydrate. For example, I have tried small amounts of berries on different occasions. More times than not, I miscalculated the proper insulin dose for the amount of fruit I had planned to eat and ended up with a high (or low) BG reading. To me, the "pleasure" of eating fruit or any food for that matter doesn't compensate for the interference with my goal of excellent diabetes management. This also points out that for insulin-requiring diabetes the lower the carb intake, the easier it is to manage. My solution was to just eliminate fruit. There are no important nutrients in fruit that can't be obtained from non-starchy vegetables.

In summary, each individual needs to determine what degree of carbohydrate restriction will result in achieving their goals and will result in a diet that they can stick with for the rest of their life. No diet plan will work if you don't stick with it, so if you have to compromise your results a little to stick to it as apposed to going off the rail, compromise is a better choice.

How Much Protein Is Needed?

This is difficult to answer because everyone's needs are different, but it is pretty safe to say that most people eat less protein than they should to maximize lean muscle and bone mass. Based on my study of this issue, I recommend between 1.2 and 2.2 grams/kg/day including those on a low carb ketogenic diet. On the low end are those who may require higher levels of blood ketones more so than improved muscle and bone mass. On the high end are those who require improved muscle and bone mass more so than blood ketones levels. In my ketone article, I review the details of how and why ketones are produced and what the blood levels mean. Those with chronic kidney disease are exception to the above, see below.

Obviously adding lean muscle mass is an important concern for athletes, but it is under recognized that as we age we lose lean muscle and bone mass due to both lack of dietary protein intake and lack of resistance exercise. This is called sarcopenia of aging and results in loss of function and independence as well as falls causing hip fractures and fatal head injuries.

Many are not aware that amino acids, the building blocks of protein,  are not stored by the body. That is, no protein exists whose sole function is to maintain a supply of amino acids for future use. Most are aware that we can store excess fat and carbohydrates for later use in adipose tissue, liver, and muscle.

The amino acids that circulate in the body are called the amino acid pool and amounts to only about 100 grams of protein in a 70-kg man.

The amino acid pool is supplied by three sources:

  1. amino acids derived from dietary protein
  2. amino acids provided by the degradation of body proteins
  3. synthesis of nonessential amino acids from simple intermediates of metabolism

Conversely, the amino acid pool is depleted by three routes:

  1. synthesis of body protein
  2. amino acids consumed as precursors of essential nitrogen-containing small molecules
  3. conversion of amino acids to glucose, glycogen, fatty acids, ketone bodies, or burned for energy, releasing carbon dioxide and water 

In order to maintain our lean muscle and bone mass, we have to eat enough dietary protein to keep the inputs at least equal to the outputs, so to speak. To increase  lean muscle and bone mass, we have to eat more dietary protein to keep the inputs greater than the outputs. However, eating more protein will not build muscle by itself. Resistance exercise is necessary to stimulate muscle growth. The dietary protein facilitates the growth under the stimulus of exercise.

Some studies have found that elderly persons have reduced muscle protein synthesis (anabolic resistance) in response to dietary protein as well as to resistance exercise (weight training). This simply means that elderly persons may require a higher dose of dietary protein intake and resistance exercise to achieve the same amount of muscle protein synthesis as occurs in younger persons. In practice this means as we get older, we need to emphasize eating more protein and lifting more weights, not less. A higher-protein diet has also been shown to improve bone density. Osteoporosis is also in epidemic proportions with 25% of elderly females have this condition. Osteoporosis contributes to hip and other bone fractures. Half of elderly persons with hip fracture die within one year. 

Is there such a thing as eating too much protein? There aren't many long-term studies of high-protein diets, however, so far no studies have found any harm associated with high-protein diets except in persons with chronic kidney disease. The current recommendation for this later group is 0.6 – 0.75 grams protein/kg/day. One of the positive attributes of a high-protein diet is that it is satiating and in effect is self-limiting. See here. What does our body do with any excess dietary protein? It simply burning it as energy or converts it to glucose or fat and stores it as glycogen in muscle and liver or as fat in muscle and adipose (fat) tissue. You might ask, "For those who need to lose excess body fat, should they reduce their protein intake?" Probably not. Of course their are exceptions, but in general when caloric intake is reduced which is required to lose body fat, maintaining a higher protein intake will promote primarily fat loss. Where as reducing caloric intake in the setting of a lower protein intake, results in roughly equal fat and muscle mass loss.

Thus, a higher protein intake minimizes the amount of lean mass lost. This study used the protein-sparing modified fast, an 800 kcal/day diet consisting of lean meat, fish, or fowl divided into two or three meals per day. The protein intake was 1.5 grams protein/kg/day. The average weight loss was 41 lb. at the end of the diet and maintenance phase. This study in adolescents used a modified protein-sparing modified fast which provided 1.5 grams protein/kg/day as well and achieved a 25 lb. weight loss at 6 months followup.

Except for persons with preexisting chronic kidney disease, dietary protein intake  should be between 1.2 and 2.2 grams/kg/day including those on a low carb ketogenic diet. Some may wonder if a high-protein intake might reduce ketone production. In short, it may or may not affect the measured blood ketone results. Everyone is different. But, the real benefit of a ketogenic diet is not solely related to its ability to raise blood ketones. The benefit is in reversing insulin resistance, normalizing insulin and glucose levels, shedding excess body fat, as well as other metabolic improvements. In my view, these benefits are much more important than the blood ketone level. I have measured my blood ketone levels about 80 times and could not find any benefit from knowing what it was, i.e. blood ketone levels did not correlate with anything related to my diabetes management. This statement may not apply to other conditions not emphasized on this website including epilepsy and neurologic conditions. Persons trying to lose excess body fat should be taking 1.5 grams protein/kg/day where as growing children and adolescents or those trying to gain muscle mass or not lose muscle mass can take higher amounts up to about 2.2 grams protein/kg/day. FYI, I am 58 yo and have a goal of maximizing my muscle and bone mass for olympic weightlifting as well as controlling my T1DM with a low carb ketogenic diet. My daily protein intake is currently 1.8 grams protein/kg/day. Of course, there will be some rare exceptions, like professional bodybuilders or strongmen competitors who may feel they get benefit from more protein.

How Much Fat Is Needed?

This is a confusing topic for many people who are interested in a low carb ketogenic diet. Another commonly used name for it is low-carb high-fat (LCHF). They will assume that means in order to successful following this diet that they need to eat a lot of fat, start eating fat that they never ate before, or add fat and oil to salads, vegetables, etc. Well, that could be true for some people. But for others, especially those with insulin resistance or those trying to lose excess body fat, this idea of high-fat can result in weight gain, no weight loss, or a stall in weight loss. The term LCHF was really meant to describe that fact that if you calculate the percentage of calories coming from fat versus carbs or protein, that it is indeed more calories coming from fat i.e. it is high-fat.

The point here is that fat, just like carbs and protein, needs to be adjusted to one's individuals goals.

For someone who is underweight but needs to restrict carbs due to a metabolic condition, emphasizing protein and adding some extra fat from cream, cheese, yogurt, coconut, palm, or olive oil makes sense.

For someone who is lean and wants to stay that way, using a little butter on vegetables, or olive oil on salad makes sense. I am in this category, but found I enjoy eating nuts and seeds more than using butter and olive oil and choose fattier cuts of meat as opposed to lean meat. This works for me, but that are many ways to get to the same end point.

For someone who is overweight and wants to lose excess body fat, there is no need to add butter or oils to the diet. They may also need to limit or eliminate nuts which are 80% fat, limit or eliminate dairy products, or choose leaner meats. For weight loss, there is no magic component of a ketogenic diet that results in weight loss no matter how much fat you eat. There could be some metabolic advantage of ketogenic diets, however, the effect is small. The real advantage of a ketogenic diet for weight loss is the improvement in and ultimately resolution of insulin resistance combined with improvement in satiety and reduction in cravings for refined carbohydrates and sugars which do indeed wreck your metabolism. The improvement in satiety makes reducing total caloric intake possible without hunger. Because the presence of excess body fat produces adipokines which contribute to insulin resistance, loss of the excess body fat is needed to completely resolve insulin resistance. So it is the combination of the low carb intake, net negative caloric intake and resolution of excess body fat that eventually reverse insulin resistance. Thus, limiting fat intake is part of creating that net negative caloric intake. Practically this can be accomplished by counting calories, but it can also be accomplished by focusing on the quantity and types of high-fat foods. In other words, deciding how much food to eat by portions either visually (thumb size, fist size, quarter of a plate, etc.) or measured (volume or weight). Do that consistently over several weeks and judge the results (body weight or waist circumference or how clothes fit, etc.) and then adjust if you are not making progress. Remember weight gain usually occurs over a long period of time and in most cases does not need to be resolved in a major rush.

How to Avoid Side-Effects

One of the beneficial effects of a low carb ketogenic diet is that it reduces insulin levels in persons with working pancreatic beta-cells or similarly results in a reduction in the insulin dose needs for those with insulin-requiring diabetes. Either way, the kidneys that control fluid, electrolyte, and mineral balances do so under the influence of insulin. Thus, as soon as the kidneys detect the reduction in insulin, they increase excretion of fluid, electrolytes (primarily sodium and potassium), and minerals (primarily magnesium). If you do not increase the amount of water you drink and do not return to using your salt shaker, you could become depleted in fluid, electrolytes, and minerals. This results in dehydration which has various symptoms and you may experience one or more of them.

  • Keto Flu - this is described as a feeling of generalized body aches, headaches, and fatigue as if you had a flu.
  • Headache
  • Dizziness, especially when standing up
  • Constipation
  • Muscle cramps
  • Low Blood Pressure - aggravated when taking medications for high blood pressure or diuretics for fluid retaining states like congestive heart failure, nephrotic syndrome, and others.
  • Reduction in kidney function as measured by an increase in blood urea nitrogen (BUN) and serum creatinine both of which increase when dehydrated. This can be quickly reversed as soon as the dehydration is corrected.
  • Increase in serum uric acid and rarely an acute gout attack in someone with a history of gout. The increase in uric acid due to dehydration can be quickly reversed as soon as the dehydration is corrected. During the first two weeks on ketogenic diet, the serum uric acid can increase for another reason as well. The kidney uses the same transporter to excrete both uric acid and ketones. When first beginning a ketogenic diet, ketones are made by the liver and blood ketone levels increase and the kidneys excrete some of the ketones. The ketones compete with uric acid for the use of the transporter. The kidney adapts over the first few weeks on the ketogenic diet and uric acid levels return to the previous levels, or possible decrease if the uric acid was elevated to the prior excess consumption of fructose or alcohol both of which increase uric acid production.

The above also helps explain why if you have any medical conditions and/or take medications, you should be monitored by your physician. There are many things that your physician can anticipate that you would never have thought about. The same can be said in what follows. The methods needed to prevent or treat these problems as depends on whether or not you have any medical conditions or take any medications.

Prevent or Treat Dehydration

In persons without any medical conditions to taking medications simply increase the amount of water you drink daily and use your salt shaker with each meal. Sometimes using lite salt helps as well. Lite salt (check the ingredients) contains about half sodium chloride and half potassium chloride. Magnesium is also useful in some cases. Magnesium is contained in pumpkin seeds and green leafy vegetables, but you can also buy magnesium chloride on Amazon or use Slow-Mag from your pharmacy or Amazon at a dose of about 300-600 mg total divided into two doses daily for about two weeks. Magnesium deficiency is fairly common and is not necessarily related to a ketogenic diet. Replacing magnesium sometimes also helps with muscle cramps, although just dehydration or too much or too little exercise can also lead to muscle cramps.

My final caution: if you have chronic kidney disease or kidney failure, or any fluid retaining condition like congestive heart failure, lymphedema, nephrotic syndrome, or liver failure, and some others you must talk to your physician before increasing your fluid, sodium, potassium, or magnesium intake. Overdoing your fluid, sodium, potassium, or magnesium intake in these conditions can result in deterioration in your medical condition, create a medical emergency, lead to hospitalization, or lead to your death. No joking!

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