July 7, 2015

Stop Saying "Ketogenic" When You Mean Low Carb

I’ve received a spate of inquiries from prospective clients recently that start off something like this:

“Hi, Amy, I’m interested in starting a ketogenic diet. Please let me know when we can set up an appointment.”

My initial response to these inquiries is:

“Hi ______,

Thanks for getting in touch. Do you mind if I ask why you’re interested in a ketogenic diet? Do you have a specific medical condition you’re looking to improve? Or if this is for weight loss, what is your current weight, and how much are you looking to lose?”

Once in a while, it’s someone with an autoimmune condition, and I’ve had a couple of inquiries about cancer, but the majority of people I hear from do not require a ketogenic diet. That is, not a classical ketogenic diet.

In case you missed it, there’s been a lot of controversy in the low-carb, keto, and Paleo worlds lately. Some prominent personalities have been sounding the alarm about the potential dangers of ketogenic diets, and in response, hardcore keto loyalists have been firing back. I’m not going to name names here. First, most of you probably already know who I’m referring to, and second, I see no reason to single anyone out, especially when I think there are legitimate arguments on both sides, and in the end, it probably does everybody good to have more information, and make decisions for themselves. (Also, I am the world’s biggest coward one of the least confrontational people around, and I like to keep the peace.)

I really have no skin in this game. I’ve told some clients to eat fewer carbs; I’ve told other clients to eat more carbs. There is no one-size-fits-all approach that works for everyone. If there was, I wouldn’t have clients in the first place, because no one would need my help figuring out why things aren’t working for them. They could read Practical Paleo, go to the grocery store, and be in perfect health and at their ideal weight a few months later.

I’ll let people who enjoy getting involved in pissing contests duke out the details. The issue I want to address in this post is exactly what the title says: stop saying ketogenic when you mean low carb.

When a prospective client reaches out to me, and the only thing I know about them from that first email is that they’re interested in a ketogenic diet, the reason I ask why is because I think people are beginning to use the terms “ketogenic” and “low carb” interchangeably, and they’re not. And I suspect that some of the people writing to me would probably do just fine on a low carb diet (LCD), and don’t have to be so strict as to follow a ketogenic diet (KD).

Let’s clarify the terms here. “LCD” is a fairly nebulous description, but that’s as it should be. Low carb for one person might be 40g of CHO/day, and for someone else, it might be 100-125g/day. That’s a big difference, but they’re both LC, in my book. (Heck, compared to 250g/day, even 150g/day could be considered low!) Plus, this is relative. Are we talking about a 110-pound female, or a 245-pound male? An elite athlete, or someone who doesn’t know a dumbbell from a cowbell? The amount of carbohydrate that might be considered “low carb” could depend on total caloric intake, too. Is someone eating 1700 calories/day, or 3000? As a percentage, 10%, 15%, or 20% of calories from CHO—all of which most of us would consider low carb, at least, compared to the SAD—would translate to very different absolute grams of CHO, depending on the total calories.

The reason I think it’s important to distinguish between LCDs and KDs is, in order to be most effective, a classic KD—as used to manage serious medical conditions—may require certain adjustments that a garden-variety LCD does not.

A standard-type LCD can be considered “ketogenic” in that it can, and often does, produce elevated levels of blood/breath/urine ketones, but a straight-up, no kidding KD requires much more attention to detail than just watching one's carb intake. A true medical-type KD is usually implemented at a 3:1 or 4:1 ratio – that is, 3 or 4 parts fat to 1 part combined carbohydrate and protein. The limitation on protein might be the single biggest difference between a KD and a LCD. There are, of course, many low-carbers who find that they lose weight, maintain weight loss, and just feel better overall when not gorging on protein, but they don’t necessarily have to weigh and measure things to make sure they’re not exceeding some kind of “safe” threshold for protein.

The other big difference, of course, is carbohydrate. There is a gulf of difference between a diet that is upwards of 80% fat and restricted in protein, and one that is 50-65% fat and unrestricted in protein and low-carb vegetables. Someone on a LCD doesn’t have to monitor the carbs in, say, almonds and pistachios, to the extent that someone on a KD might. They don't need to add copious amounts of butter or oil to other foods for the sole purpose of arriving at some magic ratio of fat to protein & carbs.

The degree to which things (might) require micromanaging is another big difference between a LCD and a KD. I am a huge fan of Mark’s Sisson’s philosophy of getting the biggest benefit with the least amount of sacrifice, deprivation, and self-immolation. It’s certainly not impossible to adhere to a KD in the real world, in restaurants, and at social functions, but it’s not exactly easy. A simpler LCD expands the options and takes some of the pressure off. (And the consequences of “cheating” or “treating” or whatever you want to call it, are less severe for someone following a LCD than for someone following a KD specifically to manage an otherwise intractable medical condition.)

Some people need a medically-oriented ketogenic intervention. Some don't. If you don’t, you can still do one. Nobody’s stopping you. But why would you? Why would you choose to eat in such a way that limits the amount of spinach, or cauliflower, or tomatoes, or steak, or lamb you can consume? (Please don’t start in with the animals only/zero carb arguments. Yes, I acknowledge and respect that there are people thriving on diets completely free of plant foods. I will be dedicating a few posts to that in the future. Here, I am talking specifically about people who do not have issues for which no other approach was effective—not Paleo, not low-carb, not SCD, not the autoimmune protocol, and not even keto that included plant matter.) Why would you choose an eating plan that requires close monitoring and micromanaging unless you absolutely had to?

Low carb diets are not necessarily about maintaining blood glucose as low as possible, all the time, as might be the case for cancer, or keeping ketones very high, as might be the case for certain neurological or psychological conditions. Yes, managing blood glucose and insulin levels is a pretty great reason to adopt a LCD, but, barring serious metabolic compromises, that’s usually a happy byproduct of following a good LCD. There’s no need to whip out meters and lancets and log books at every meal or snack. A LCD comes (or should come) without the obsessive compulsion to measure and track all the time, which can lead to some pretty gnarly self-judgment when blood glucose isn’t low “enough,” or ketones aren’t high enough. So many factors play into these things besides just the foods we eat, but people have a tendency to feel like failures if the numbers at any given time aren’t what they were hoping for. (Please note, I’m not saying people shouldn’t track things, especially on true KDs. They probably should. But for regular ol’ LCDs? Sure, maybe at first, for newbies to get an idea of what pancakes do to them, versus a fatty pork chop, but after a while, the LC dieters can loosen up a little more than the keto dieters.)

As for people sounding the alarm about potential pitfalls on KDs, I don’t think they’re entirely out of line. KDs can present risks that standard-type LCDs usually circumvent. But all this means is that the KD should be evaluated for nutrient & electrolyte content, to make sure nothing gets too out of whack, and it might not be a bad idea to try and spread some of the fatty acids out to be accounted for by saturated, mono-, and polyunsaturated fats (including MCTs and omega-3s). Some of the medical-intervention ketogenic diets call for commercially prepared ketogenic-ratio shakes, kind of like Ensure, but specifically formulated for that 4:1 or 3:1 keto ratio, and the fat is predominantly n-6 heavy vegetable oil. I think some of the problems that present with classic KDs are a result of them just being poorly formulated, with absolute garbage substituting for food. (i.e. soy protein, casein, soybean oil, corn syrup, maltodextrin, etc.) And, of course, it’s possible, just possible, that some people really do have better health on slightly more carbs. Maybe some of the women (it’s usually women) who claim their thyroid died, or their adrenals tanked, or all sorts of other world-shattering, disastrous, stop-the-presses things happened while super-low-carb, would have absolutely thrived on a diet of 20% or 25% carb, rather than 10%. After all, a diet of 20% carb could be 55% fat and 25% protein, which might not be ketogenic, but most of us would still consider it to be low carb. (For you ultra-purists out there, sure, maybe its not super low carb, but its certainly low carb compared to the standard American diet, no?)

My guess is that some of the people who claim low-carb killed their thyroid, derailed their menstrual cycle, and all that other stuff, were following very low carb diets while also overtraining, not sleeping enough, having other sources of mental & emotional stress, and very likely, most probably, ding-ding-ding, we have a winner -- not eating enough total calories. Women of all ages, but particularly, young women, tend to fall into this calorie hole. Was it low-carb that derailed their hormones, or was it trying to burn not one candle at both ends, but more like ten candles at three ends (if thats even possible), while basically starving themselves? Whether or not they were aware of it, that may be what was happening: at a cellular level, they were starving. (Even if they didn't feel especially hungry throughout the day. I’m talking about the cellular level, where we’re not always cognizant of what’s going on.)

YMMV, but I think the majority of folks who are overweight, insulin resistant, diabetic, struggling with PCOS, and more, will see great results by just going low carb. That should be the starting point. A good ol’ LCD, as laid out in the original or 1990s versions of Dr. Atkins' New Diet Revolution, or Protein Power, or the lower-carb options presented in Practical Paleo or The Primal Blueprint. People can fiddle with things from there, if they do not get the results they were hoping for:

There are some people who will benefit from going the extra mile and adopting a true ketogenic diet -- or, really, in some cases, just an "ultra low carb" diet, as Kiefer might call it. Aside from the obvious ones (cancer, Alzheimer’s, epilepsy, and other neurological conditions, such as MS and ALS), other conditions that might (might) respond exceptionally well to a ketogenic approach are mood/psychological disorders, the management of which may depend on optimizing brain function and neurotransmitter levels.

Higher carbs, lower carbs, low-carb diets, ketogenic diets, low FODMAPs, low histamines, no plant foods: different tools for different goals. (Not everything is a nail; therefore, we need other tools besides just hammers, capice?)

As for the ongoing mudslinging between the various factions of Paleo, Primal, low carb, and keto, I stand by what I’ve always believed: we agree on so much more than we disagree on. The primary underlying principles of all of these approaches basically overlap: reduce or eliminate grains, refined sugars, processed foods, and vegetable & seed oils; focus on good quality animal foods; don’t fear naturally occurring fat. The restFODMAPs, salicylates, the gut biome, whether or not plant foods are essential—is just details. We have enough to debate from the camp that thinks endless acres of corn and soybeans—and the imitation meat products made from them—are the salvation of the entire human race and all the ecosystems on Earth. I’d like to see us stop wasting time and energy fighting among ourselves.

Remember: Amy Berger, M.S., NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition.


  1. Great post, I needed this, a voice of common sense in this crazy world of diet/health/nutrition. I just want to say though from the point of view of 'us' out there, can you blame us with all the conflicting information? You got ZCers, Rosedale etc on one end warning that all glucose is bad..Kiefer as you mention is LC but we NEED a carbnite every now to 'reset'..JM who thinks we should nom the butter, Jaminet who says we should eat rice ...Richard Nik who believes we should add the taters and starches..Mark says peanuts are bad but Bill says they're good..and then Carbsane who thinks EVERYONE is wrong...aghhh....it's a wonder we don't just give up!

    1. To be honest, sometimes I hover at the verge of giving up, myself! Whatever education I have in all this, I'm still not immune to the confusion and frustration. I would say the hardest thing about finding what works is just that: finding what works. Is that going to be low-carb? Full-on keto? Strict Paleo? More vegetables and safe starches? It's enough to make anyone's head spin -- including mine! I think we just need to focus on what our goals are, and what the most likely path is that will get us there from our starting point. And after a while, if things aren't going in that direction, re-evaluate and try something different. I find that some people don't give their bodies enough time to adjust to certain things, and maybe they hop from approach to approach every 2 weeks. Well, no wonder things are all over the map. ;-)

      I'm almost done reading Jaminet's book, and it's been fascinating. I must admit, I've been more and more intrigued by the zero-plant angle, but PHD makes so much sense and is so reasonable. People are starting to become afraid of broccoli, for cryin' out loud. (And like I said, there *are* people who do really well on little to no plant matter. I get that. But people [like me!] who don't absolutely require that drastic a strategy are starting to question eating innocuous -- and delicious -- things like zucchini, red peppers, etc.) In fact, I learned something very interesting about myself and my own nutrition from PHD -- something that explains a couple of anomalies in bloodwork I had done recently. Blog post about that coming soon. I've changed my diet a little and already feel better, after just a few days. And that said, the changes don't involve white rice and potatoes. Even if a certain strategy works well, we still have to tinker with it to make it ideal for ourselves as individuals, and total carbohydrate intake is probably one of the most important factors of all.

      P.S. I eat peanuts! (Probably way too many, in fact. Damn those insanely delicious Trader Joe's blister peanuts...)

    2. In my experience, the danger of the Jaminets' notions is that they SOUND logical, but do not pan out in real life. "Common sense is the sense that tells us the earth is flat." A couple of years ago, i have their ideas a try, and ended up gaining weight ... because what seems reasonable when it comes to fat gain/loss just ISN'T TRUE.

      And you must also remember that "being afraid of broccoli" is a rational thing, if one is sensitive to goitrogens. Ditto, for nightshades. Some of us really don't tolerate vegetables well, and if we're happy limiting ourselves, forcing our microbiomes to "help" us ferment them more is NOT a great idea.

    3. I'm with ya, Tess. I've found a few things in PHD that resonate with me, but there were others that I was calling BS on in my mind. Some of the logic is spurious. I think the same principle applies to PHD as should apply to any other dietary advice: take that which is helpful and discard the rest. (I am butchering a Bruce Lee quote there.) And I'm also with ya on the goitrogen & nightshade issue. (And extend that to everything else: salicylates, histamines, etc.) I recognize that removing particular elements from the diet is hugely helpful for some people. And people with clusters of odd, unresolved symptoms should look into some of those intolerances as possibly being the culprit(s).

      I do think, though, that some of the scare-mongering is leading people to fear foods that are actually not problematic at all -- *for them.* This is why I have so much self-doubt and am in "existential crisis" mode as a nutritionist. It's so much more complicated than people realize, and it's actually really freakin' hard to help people! Aaaaah! A good, basic low carb diet will take many people a great deal of the way, but when it comes to the nitty gritty of resolving those last little nagging health issues, or dropping the last few stubborn pounds, the possibilities of what to try are endless.

      My new motto needs to be: The more I learn, the less I know. (If only I would stop reading so damn much, I'd probably feel like the world's most informed expert!)

    4. "it's actually really freakin' hard to help people" ... I can well imagine your frustration. :-) hang in there, Amy -- you're REALLY performing a service!

  2. That was my response, to, when the anti-keto attach came out at Paleofx (or another conference) - we have so much more in common than we have differences!!! Please, no circular fitting squads!
    And, the idea promoted within keto and LC communities, that we need to check our blood sugar all the time, when we *are not diabetic* is just exhausting (not to mention wasteful). Same with measuring ketones, and buying a freaking $200 tool to do it! It's not a coincidence, I think, that the people promoting these beliefs, while big names, usually have no professional training / experience in nutrition or medicine. We *need* people like you - with this training/experience - to weigh in, so thank you for doing so.

    1. And thank YOU for this nice note. :) I've had to talk a couple of clients down from the ledge, so to speak. People really drive themselves nuts with the numbers, and the measurements, and the micromanaging, and it really works against health and wellness in some ways. Tracking data serves a useful purpose, but the end goal is to *feel well* (and look good, for some people). People might be surprised that having the lowest possible glucose at all times, or the highest possible ketones, doesn't always go hand-in-hand with that goal. At some point, you have to just eat and live. People forget how much stress and "food fear" can impact the way the body works, regardless of how "clean" or "perfect" the diet is.

      I try to be a voice of reason, because things are so contentious, and that's not helping anyone.

    2. Fully agree with Wendy and Amy.

  3. Not that I disagree on the practical advice but I think an absolute, non-arbitrary definition of low carb is needed in order to clasify research correctly. I think 150g-CHO/day is it.

    1. Good point. I think I'd like to see it even lower, though, maybe like 100g/day, but we do need some kind of standard. There are too many studies out there that call 40% CHO "low carb." And yeah, maybe compared to 50-60% CHO, like a typical American diet, 40% *is* low, but it's probably not low *enough* to induce the metabolic improvements we expect from LC diets. (And now that I think more about it, 150g as a maximum is probably pretty good...especially compared to the 250g+ many people typically consume.)

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  5. Re: young women not eating enough calories and then blaming the LC diet for their health problems, I agree. I noticed the problem a few years ago when IF, crossfit, and eating vegetables literally by the pound were all in vogue. And their health problems would suddenly go away when they ate "more carbs" like sweet potatoes (served with coconut oil or butter, no doubt)--aka more calories.

  6. I came up as hypothyroid when I was about 4 or 5 months into low carb, but when I sat down and calculated my caloric intake I was surprised that it was very low--about 900 to 1100 k/cal a day. I was referred to an endocrinologist who assured me that my low caloric intake could NOT be responsible for the hypothyroidism (measured only by TSH, thanks to my HMO). She threw an Rx at me for Synthroid which I did not take.

    I upped my calories to 1200 to 1400 and my thyroid was back in a "normal" range when it was next tested. The endocrinologist congratulated herself for guessing the right dosage off the bat on the Synthroid and when I told her I never took it she still wanted me to???

    N=1, but caloric intake, not low carbing, had an impact on my thyroid.

  7. YMMV indeed, but you'll never truly know unless you have an insulin assay done, as has been shown by Kraft and Reaven (discussed recently by various people).

    I am strictly keto because it works best for me - I find it easiest to follow and keeps various conditions under control. I care little about cholesterol, etc. You can't worry about everything. But my wife does eat PHD ratios and has little inclination to do otherwise. She feels great, has perfect weight control, and 'healthy' markers. But, nevertheless, both her parents are frank diabetics, as are her siblings. Would PHD stop her from becoming IR/diabetic (in situ)? Who knows. Not her, not me, not Paul Jaminet. It's all just pure guesswork and hoping for the best as she does not know her insulin response which Kraft has shown to predate blood sugar issues by a decade or more. So everyone has to make their own decisions, but I remain unconvinced by moderate carb diets and 'safe' starches, simply because without an insulin assay you cannot know what is safe.

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  9. Great article Amy. Thanks. I have been looking for something like this for a while as I am all confused with what people are saying on LCD and KD in Facebook. People micromanaging what they are eating to the level of grams which I don't do. Kind of make me worried if I am doing it wrongly all this while. I want to enjoy my food without having worrying whether do I eat too much fat or protein, as long as I stay low carbs. I'm healthy and fit, free from diseases and there is no reason for me to go into KD.