December 28, 2016

Stop Following a Medically Therapeutic Diet "Just 'Cuz" (a.k.a. The Keto Train to CrazyTown)

This is a very long post (even for me). Take it or leave it. You have been warned. Comments have been disabled for this one. Love this post or hate it, agree with some of it, disagree with some of it. Whatever your feelings, you are free to express them elsewhere.  

This will be the last of my emotionally charged posts for a little while. I have to get it out of my system, but once it's out and the new year gets underway, I'll focus on posting things that are more educational and helpful (or intended to be, anyway).

It’s funny. Considering I advertise myself as a low carb and keto-friendly nutritionist, I often find myself recommending that clients eat more carbs. More protein. And that they abandon weighing and measuring every morsel of food and pouring olive oil and melted butter on everything in an effort to arrive at some magical, no-fail, automatic-fat-loss-inducing macronutrient ratio somewhere upward of 75% fat.

I have been threatening promising on social media for a while now that I was going to post an epic rant about some problematic things I see when healthy, fit, active people follow a medically therapeutic diet because they have come to believe they should. (Or worse, have come to believe that they have to, because it’s the only way to be healthy and prevent metabolic illness. 

Now, before I get into things, we’ve got to establish some ground rules:

  • This post is not an attack on ketogenic diets. If you think I don’t understand the therapeutic benefits of ketogenic diets, then you obviously have not been reading my blog for very long. (Shame on you. Ha! No, just kidding. If you’re new, welcome!) I have extolled the virtues of ketogenic diets in podcast interviews, in my e-book about Alzheimer’s disease (which has been completely rewritten and expanded for release by a big name publisher in March 2017, so please, don’t bother buying the e-book; wait until the new one comes out. It's much better [and available for pre-order now!]), and I’m leading up to addressing the benefits of ketogenic diets in the series I’m writing on the metabolic theory of cancer. I think ketogenic diets have tremendous potentialwhen they are applied intelligently and rationally. Unfortunately, as is true for fasting, with so many (sooo many!) people jumping onto the keto wagon these days, the words “intelligent” and “rational” aren’t applying as much as we might hope.  
  • This post is not a personal attack on anyone. As always, if what you’re doing is working, then keep doing it! If you eat a certain way, and you feel well, have enough energy to do the things you enjoy doing, and you’re happy with your moods, cognition, body composition, emotional well-being, and whatever biomarkers you like to keep track of, then by all means, keep eating that way! If you enjoy following a strict ketogenic diet, then keep following it.

So if this post is not about those things, then what is it about, and why am I writing it?

It is not my goal to preach, proselytize, or “convert” anybody into following or not following any particular diet. The funny thing is, despite being a low carb, Paleo, and keto-friendly nutritionist, the truth is, I don’t give one flyin’ hang what you eat. The reason I’m writing this is because it needs to be written. (And either no one else is as riled up about these issues as I am, or no one else has the courage to call people out on their nonsense, so if I want this message to get out, then it’s up to me to do it.)

I am writing this because even though strict ketogenic diets can be great—GREAT—for many people for many reasons, they might not be appropriate for everyone, all the time.

I see this time and again in clients.  Much like what I said about fasting, the reason I have to tell both sides of the story is because I see the effects of what happens when people don’t fare so well on super-strict ketogenic diets. Just because something works like magic for one person doesn’t mean it’s going to work equally well for everyone else at all times. I receive inquiries from people following very high fat, very low carb diets, and they feel fatigued, anxious, weak, depressed, their athletic performance is regressing, and maybe they’re even gaining body fat. (Yes, even when insulin levels are low, they’re gaining fat.) So, like my fasting post, if you feel fine following a super-strict ketogenic diet, then keep following it. This post is about people who don’t feel fine.

Allow me to reiterate, because past experience has shown me that no matter how clearly I explain myself, someone will always get their panties in a bunch by trying to apply what I say to their unique snowflake situation. SO: if you have been following a long-term super-strict ketogenic diet and feel that you are at your physical, mental, emotional, and cognitive best, carry on! This post is not for you. This post is for people who do not fit that description. I am daring to suggest that maybe—just maybethis one, single approach might not be the best way for everyone, everywhere, no matter their circumstances—to eat.

Here’s where things get a bit gnarly, and I have to muster up the courage to just say what needs to be said: it is noteworthy how much any way of eating with a particular label affixed to it—be it Paleo, low carb, ketogenic, vegan, vegetarian, or something else—seems to attract individuals with borderline or full-blown eating disorders or obsessive/neurotic tendencies.

I am not a psychiatrist. I can’t help these people with their food “issues.” If they’re scared to eat altogether, or scared to eat certain foods, there’s not a whole lot I can do about that. All I can do is bring their attention to it, and make them aware that I didn’t just fall off the turnip truck and they ain’t hidin’ anything from me. I do it as kindly and as gently as I can, but I do try to point out that they do not have a healthy relationship with food, and that the level of restriction and regimentation they are imposing on themselves is likely a direct cause of the things they have contacted me for help with: fatigue, anxiety, depression, amenorrhea, lethargy, weight gain, and more. 

Just as with fasting, it seems that the majority of people who experience these issues from a ketogenic diet are women. (I guess it would be pretty strange if a man wrote to me asking for help with his amenorrhea…) They’re almost always women. Women who usually, but not always, have a history of anorexia, vegetarianism, veganism, or raw foodism. They use keto as another way to restrict food while pretending they have healed their relationship with food and with their bodies. There is a lot of orthorexia and anorexia in KetoLand™. A lot. These individuals use keto to pretend like they’re eating normally, but the degree to which they restrict and the degree to which they are straight up afraid of perfectly benign foods is still massively disordered behavior around food. (They are still essentially starving themselves for total calories as well as micronutrients; they just happen to be doing so while eating a small amount of food that sticks to rigorously imposed ketogenic percentages.)

To be clear, it’s not always women who run into trouble on long-term uber-strict keto. There are plenty of men who get themselves into these messes too. I see them on social media all the time. When I work with clients like this, in trying to get them to even think about expanding their diet, I point out that even though they’re afraid to start eating certain foods again, they can acknowledge that what they’re doing now isn’t working. They don’t feel their best. If they did feel well, and if they had no physical or psychological ailments bothering them, they wouldn’t have contacted me for help. They might need some time to get used to the idea of eating more food, and eating a wider variety of food—especially carbohydrates—but they can at least see that something has to change, because they’re not getting anywhere by doing what they’ve been doing.

With that in mind:

Dear healthy, young, fit, lean, athletic people who DO NOT FEEL WELL: Please stop following a medically therapeutic ketogenic diet.

In my blog and with my clients, I try to differentiate between ketogenic diets and low carbohydrate diets. They are not the same. I think semantics is starting to get us in trouble. These terms are not interchangeable, but many people are using them as if they were. And as I have written about before, a great number of people who would do just beautifully on a low carb diet have somehow convinced themselves that they must be strictly ketogenic, and stay strictly ketogenic at all times, forever and ever, even when they don’t feel well anymore. So before I go on, I should probably define some terms, or, if not define them, then at least share my thoughts:

Low carb diet (LCD):  This is very hard to define, because, well, it’s not defined. For my purposes, I’ll say it’s a diet under 100 grams of carbs per day. Obviously, compared to a ketogenic diet, 100g of carbs is high, but compared to a standard American or modern Western diet, it’s low. For reasons I’ll explain in a minute, I dislike going by percentages and I think percentages are quite problematic, but since many other people seem to be so hung up on that: for someone eating 2000 calories per day, 100g of carbs (400 calories) would be a mere 20% of total calories. Compared to the 40-60% of total cals from carbs that millions of people consume daily, 20% is plenty low. On plain ol’ low carb diets, protein is not restricted, and while fat is also not restricted, people are not encouraged to add unlimited amounts of extra fat in order to arrive at some pre-determined ratio. (Notice I have called this low carb, but not “low carb, high fat.” Just low carb.)

Medically therapeutic ketogenic diet (MTKD):  A diet formulated to have a ratio of approximately 3:1 or 4:1 of fat to combined protein and carbs. (That is, 3 or 4 times as much fat as protein and carbs combined.) This typically means that in addition to restricting carbohydrate, protein must also be restricted, and the major emphasis is on fat. Some people like to give percentages instead, for example: 77% of total calories from fat, 13% from protein, and 10% from carbohydrate. As I said, I’m not a big fan of the percentage model. Percentages don’t tell us much, because depending on someone’s total caloric intake, the absolute grams of any of these things could vary significantly. (For example: on a diet of 1800 calories per day, 10% of carbs is 180 calories, or 45 grams, but on a diet of 8000 calories per day, 10% would be 800 calories, or 200 grams of carbs, which would pretty much prevent ketosis regardless of how much fat was being consumed. I realize this is an extreme example, and it’s unlikely that anyone aiming to be in ketosis would be eating 8000 calories per day, but it’s just to show the point: percentages don’t mean much. Someone eating 77% of calories from fat and 10% from carbohydrates will not be in ketosis if their total caloric intake is massive. The ketogenic state has more to do with what is lacking in the diet [carbohydrate] than what is present in large quantities [fat]. More on this in a bit.) For a MTKD, whatever parameters are used regarding ratios or percentages, carbohydrate intake is usually limited to 20-30g per day or less.

Ketogenic diet (KD):  I’m not sure how to differentiate this from a MTKD, except that the people who follow a “ketogenic diet” and use the term relatively loosely tend to focus on the carbohydrate restriction angle. These more “casual keto” diets -- not super-strict ones being used as medical therapy -- are usually less than 30g of carbohydrate per day (with some insisting this be total carbs, and others insisting it’s net carbs [total carbs minus fiber]). Beyond that, protein is not restricted, and fat is more variable: eat more fat, eat less fat, depending on your goals. But gobs and gobs of extra fat arent required in order to achieve a specific ratio or percentage. The main difference between “casual keto” and low carb is that even though low carb is still ... well, low carb, it might be higher than 30g of CHO per day. But they're similar in that protein and fat are modulated based on someone's goals (changing body composition, in particular), and not pre-determined by a set ratio.

What these three approaches have in common is carbohydrate restriction, albeit to varying degrees. Where they mostly differ is in protein and fat.

In a nutshell:

MTKD:  Very low carb, very high fat, reduced protein
KD:  Very low carb, moderate fat & protein, or “adequate” protein, adjustable fat
LCD:  Lower carb than standard diet, but not always as low as ketogenic; adequate protein, no particular emphasis on fat loading. (Emphasis on low carb, rather than high fat.)

I think where people run into trouble is in following a MTKD when they would fare just fine—if not better—on a low carb diet or ketogenic diet unrestricted in protein and without following orders from on high to add gobs of extra fat to everything. And in this case, when I say “MTKD,” I mean that people are aiming for what they have internalized to be some kind of “magical ketogenic percentages”—so, not necessarily the 3:1 or 4:1 math. Basically, they’re aiming for very high fat, very little carbohydrate, and just enough protein to not die. (Usually going for 70% or more of total calories from fat.) It seems to me that most of the problems that arise on ketogenic diets are the result of people chasing these magical percentages without much of a pressing reason for doing so.

Before that, though, let me address an even more important issue than low protein, ultra-high fat, and ultra-low carbs…


Electrolyte imbalance/insufficiency is probably the single most common and easily correctable culprit behind people feeling like poop on these dietsparticularly if they work out hard and sweat a lot. Y’know why sweat tastes salty? Because you lose sodium when you sweat!! Owing to the effects of insulin on the kidneys, ketogenic diets (by way of lowering insulin levels) have dramatic effects on how the kidneys reabsorb—or, as the case is, don’t reabsorb—and hang onto electrolytes, especially sodium, potassium, and magnesium. Signs & symptoms pointing to a need for more of these include fatigue, headaches, lethargy, leg cramps, edema or swelling/fluid retention (especially in the lower legs), and maybe even nausea and lightheadedness.

Bottom line: even if you’re eating plenty of green leafy vegetables (which are good sources of Mg and K), you probably still need to supplement with extra, and you definitely need to salt your food (or drink broth made with bouillon cubes). Very low carb diets are not compatible with low sodium intake, PERIOD. If your physician has prescribed a low sodium diet for you due to elevated blood pressure, please know that insulin affects blood pressure far more than sodium does, and the number 1 best thing you can do to reverse hypertension is adopt a low carb diet, or at the very least, quit sugar.

Okay, now back to magical percentages. There are four main reasons people aim for a high percentage of fat on a ketogenic diet:

  1. Disease management or prevention
  2. They believe that more fat = higher ketones and higher ketones = better results
  3. Weight loss
  4. Optimizing health

Let’s address each of these in turn.

Disease Management
or Prevention

In case you forgot from when I mentioned it way back at the beginning of this post, I am well aware of the therapeutic potential of ketogenic diets. People are using them for cancer, neurological health, mood disorders, and more. But just because ketogenic diets help people manage or reverse medical conditions doesn’t mean ketogenic diets are required to prevent those conditions from developing in the first place. I wrote about this in a guest post on Robb Wolf’s site a while back:  Calling an exterminator and having him fumigate your house will kill an insect infestation in your home, but that doesn’t mean setting off bug bombs in your house is required to prevent the infestation from occurring in the first place. You can use other, less drastic measures to ensure you don’t need the more extreme solution later on. (Better insulation on doors & windows, not leaving food out, etc.)

Has every octogenarian and nonagenarian who’s reached old age free of dementia, Parkinson’s disease, cancer, and type 2 diabetes followed a ketogenic diet? Of course not. So can we please inject some sanity into these discussions? Again, if you want to use a ketogenic diet as a potential—potential—prevention strategy, go right ahead. (I think they can work for prevention; I just don't think they're required.) But don’t scare other people on the interwebz into thinking that they also must do so, lest they damn themselves to a fate of metabolic and mitochondrial disaster because they enjoy eating a baked potato every now and then.

Yes, ketogenic diets might—might—prevent any number of chronic diseases, but the long-lived octogenarians and nonagenarians in the “blue zones” don’t follow strict ketogenic diets. Many of them have consumed bread, beans, and fruit throughout their entire lives. So even if KDs and MTKDs have a role in prolonging lifespan and healthspan, they are clearly not the only effective strategy. For many people, I would argue that adequate physical activity, maintenance of muscle mass, sufficient quantity and quality of sleep, a sense of purpose in life, a sense of humor, and a generally low carb diet would do just great. As I specified in that guest post for RW, a super-strict KD probably isn’t required to ensure lifelong health, but good glucoregulation and generally low-ish insulin levels probably are. And here’s a news flash: there are people who maintain insulin sensitivity and normal blood glucose levels on diets that include fruit, beans, and starches. (If that doesn’t describe you, then yes, perhaps you need to be on the very low end of low carb, but that doesn’t mean that everybody, everywhere, needs to be there with you.)

I’m planning a post for sometime in the new year going into a bit more detail on the following point, but here’s the nutshell version: carbohydrates, per se—from real, whole, unprocessed foods—are not poisonous. It’s almost ridiculous to even suggest this. (Yes, many plant foods contain anti-nutrients, but this is not something unique to grains and legumes. Broccoli, cauliflower, blueberries, avocado, and many other plant foods beloved to low carbers and keto adherents contain anti-nutrients as well. I'm not referring to the anti-nutrient issue here. I'm referring primarily to the effects on insulin and blood glucose.) There are many long lived and HEALTHY people who eat beans, potatoes, rice, fruit, and even ... *gasp!* ... bread. We could talk about the Okinawans, or the Kitavans, the traditional Greeks, Italians, and more. The difference is they weren’t combining those starchier foods with corn and soybean oil, refined sugar, HFCS, etc. (To say nothing of not having sedentary automobile-based existences or desk/cubicle-based jobs, and not having completely screwed up circadian rhythms.) If you can’t acknowledge the difference between parsnips and Lucky Charms cereal, then I’m not sure we’re even inhabiting the same plane of existence. I don’t know why it’s so hard for people to understand that a small bowl of rice consumed with kimchi, a fried egg, some fish, and a bit of seaweed, is not the metabolic equivalent of unlimited breadsticks and a bottomless bowl of fettuccini alfredo. Once someone is already metabolically damaged from years of ingesting the pure pile of toxic sh*t that is the “standard American diet,” then yes, perhaps they are best advised to avoid even the foods that we might otherwise deem wholesome (for example, beets, parsnips, and butternut squash). But that doesn't mean that those foods were what caused the metabolic problems in the first place. 

That ketogenic diets seem pretty close to a darn near miraculous therapy for a wide range of conditions doesn’t mean that healthy people must follow this medically therapeutic nutritional strategy in order to remain healthy. If you are a healthy, fit, strong, active individual who exercises intensely several times a week, why are you eating like a child with intractable epilepsy? What has convinced you that the percentages of fat and protein suitable for an epileptic child are suitable for you?    

Don’t apply to yourself what applies to someone else’s situation, which might have absolutely no relevance to you. Just because someone else’s child has a life-threateningly severe peanut allergy doesn’t mean you need to carry an epi pen and never shake hands with someone whose third cousin might have eaten a peanut butter and jelly sandwich two years ago if you do not have a peanut allergy, capice?

Stop following a medically therapeutic diet “just ‘cuz.”

More fat = higher ketones;
higher ketones = better results

This reminds me of the diet-heart/lipid hypothesis which, sadly, most family physicians and cardiologists still subscribe to. It’s the idea that eating cholesterol raises blood cholesterol, and high cholesterol clogs arteries and causes heart attacks. Both of these are incorrect. (That is, dietary cholesterol does not automatically become cholesterol in the blood, and high cholesterol in the blood does not “clog” the arteries or cause heart disease.) 

Similar fallacies abound with keto: more fat doesn’t always translate to higher ketones, and higher ketones don’t necessarily mean better results. What results? Well, whatever results someone is after: greater weight loss, better athletic performance, and more. I do think higher ketones can offer therapeutic benefit for cancer, mood disorders (such as anxiety or depression), traumatic brain injury, and neurological disorders. But higher ketones do not automatically and unfailingly ensure quick fat loss or setting new PRs in the gym. (“PR” stands for “personal record,” for you non-gym dwellers.)

The first thing to know here is that prominent low carb researchers Jeff Volek, PhD, RD, and Stephen Phinney, MD, PhD, consider the range of nutritional ketosis to be blood levels of βOHB at 0.5—5.0 mmol/L. So if you think you have to swill down cups of olive oil and add half a stick of butter to your morning coffee in order to reach blood ketones of 2.0 mmol/L or higher in order to be a “fat-fueled” or “keto-adapted” beast, you are misguided. If your ketones are “only” at 0.5, guess what? You’re in ketosis. Congratulations. And you know what else? People not following a ketogenic diet might wake up with βOHB at 0.1—0.3 mmol/L, so even if you’re “only” seeing ketones around 0.3 or 0.4, that could still be three or four times higher than for people consuming a typical amount of carbohydrate.

For the purpose of fat loss, having relatively low ketones doesn’t mean you’re “doing it wrong,” and you don’t need to glug down ungodly amounts of fat in order to artificially force your body to make more ketones. Again, ask yourself why you want higher ketones. Are you trying to protect healthy cells for an upcoming radiation or hyperbaric oxygen treatment for cancer? Are you an Alzheimer’s patient trying to feed starving neurons? Or have anonymous participants on an online forum convinced you that you won’t reap the benefits of carbohydrate restriction unless your ketones are above some arbitrary threshold that they can’t even explain to you?

The fact is, some people’s bodies produce higher ketones more readily than others’. It’s just the way it is. More fat might facilitate greater ketone production, in some people. (Please know I’m talking about fat in general, and not specifically coconut, palm kernel, or MCT oils, which will result in higher ketones in just about everybody, even with a concurrent high carbohydrate intake. [As Chris Masterjohn, PhD, said: “…adding MCT oil to your pasta is more ketogenic than restricting your carbohydrates to ten percent of calories.”])  Those of you who obsess over ketone levels, please, please, consult with someone who truly understands the biochemistry of this stuff, because when I see that phrase -- the dreaded one that makes me cringe ... I got kicked out of ketosis -- I know that that person has no appreciation for the complex feedback loops and regulatory processes that govern ketone production. (Not to mention gluconeogenesis and fatty acid oxidation.) There's so much more to it than most people realize. 

There are reasons to aim for high ketones, and to take deliberate measures above and beyond carbohydrate restriction to do so. But it’s all about #context. Do you need to aim for high ketones? Depends on what you’re trying to achieve. What are you wanting those ketones to do for you?

Many people seem to be going for high ketones because they think the higher their ketones, the more body fat they’ll lose, and the more quickly they’ll lose it. NOT ALWAYS

Weight Loss

Most important fact here: Ketones are the result, not the cause, of using fat for fuel. Ketones do not drive the process of “burning fat”; they are the byproduct of it.

Second most important fact: most of the people who contact me for help when their super-strict ketogenic diet has them feeling like poop do not even need to lose weight. Again, they have somehow come to believe that they need to follow a MTKD “just ‘cuz.”

Stop it.
Stop it, stop it, STOP IT!

On second thought, let me rephrase: if you feel great eating a high percentage of your calories from fat, eating just enough protein to eek out a sort-of existence, and severely limiting carbs from everything but the specific vegetables and nuts whose carb content is the lowest of the low, then keep going. Absolutely no trouble there.

But if you don’t feel so great—and I know some of you don’t—then perhaps it’s time to rethink things. This is especially true if you have implemented a ketogenic diet for the specific purpose of fat loss, and you’re not getting anywhere with that goal. (Assuming, of course, that you actually have weight to lose and you aren’t following a fat loss diet as a result of raging body dysmorphia. I’ve had clients who struggle to lose weight because they’re already at a healthy body weight, or sometimes even underweight.)

Let’s talk about stubborn fat loss first, because it’s the more common issue.

If you’re struggling to lose body fat, does it make sense to add a lot of extra fat to your food? The more fat coming into your body from food, the less your body needs to tap into its own stored fat for fuel. But that’s what you want, right—for your body to have to use its own adipose tissue for energy. That’s how we lose that fat, after all.

So here’s the deal: carbohydrate restriction prompts the body to start running on fat. It’s not the presence of large amounts of dietary fat that makes us burn fat; it’s the absence of carbohydrates.

Stated another way:

Ketosis is achieved by what is not in the diet, not by what is. It is the absence of appreciable amounts of carbohydrate that results in ketosis, not the presence of copious amounts of fat.

(Again, not talking about consuming a high amount of MCT-rich oils, which will elevate ketones even in the presence of significant dietary carbohydrate. I’m talking about what I would call “normal dietary means.”)

If lots and lots of dietary fat resulted in ketosis, then you could load up a large bagel with several tablespoons of butter or cream cheese and be in ketosis, but again, it’s not the presence of all the butter that would do it; it’s the absence of the bagel. With this in mind, burning fat in general will happen when you cut back on carbs, but burning your stored body fat, in particular, will happen when you cut back on dietary fat. In this sense, those of us using ketogenic diets for the specific purpose of fat loss (me included!) have been misled by the abbreviation “LCHF,” or low carb, high fat. As Ted Naiman, MD has explained so beautifully, if your body is already “high fat,” then all you need is the low carb:

Various sources here and there have led people to think that as long as they keep insulin levels low (by eating very little carbohydrate and also limiting protein), they’ll lose weight. It doesn’t matter how much fat they eat, as long as insulin levels are low.

It is possible to gain body fat while in ketosis.

I know this to be true because I’ve experienced it. (There’s a reason I am prohibited from keeping mayonnaise and peanut butter in my house, if you must know.) As I’ve written before: “Even if you’re in ketosis, if you’re eating several hundred (or thousand!) extra calories of pure fat, all that food energy still has to go somewhere. With or without insulin, in or out of ketosis, it’s not just going to disappear.” You can be dark purple on your ketostix or high on your blood meter all you want, and it doesn’t automatically translate to body fat loss.

So please, if you are struggling with stubborn body fat loss—and particularly if you are still quite a ways from your goal weight—stop listening to people who encourage you add fat to foods in order to make them “MOAR KETO. Remember, there is no magical ketogenic ratio, and as Dr. Naiman so simply put it, if your body is already high fat, then all you need is the low carb. Now, that doesn’t mean you will follow a low carb, low fat diet. No-sir-ee. It just means that you can eat foods that are already high in fat (ribeye steak, avocado, pork chops), but not need to add more fat in order to arrive at some mythical percentage that will result in automatic fat loss. (If only it were that simple!) Even if you do eat a relatively low amount of fat, though, if you have a significant amount of body fat to lose, guess what? You’re still eating a high fat diet, except the fat is coming from your body, rather than your plate. As a percentage of the fuel your body is using, fat is still high, even if there’s not a whole lot of it in your food. (You are “eating” your own body fat.)

This is why people you might know on Twitter and Facebook who are already lean and jacked post photos of pats of butter on top of steaks, or plates literally piled high with bacon, eggs, and avocado, and some of them also drink coffee or tea with multiple tablespoons of butter and coconut oil in them. They have “wiggle room” for increased fat intake, because they do not have as much body fat to draw on as do people with much higher body fat percentages. (They also usually do fairly hardcore workouts and need the refueling in order to perform well at the next effort.)

When you are brand new to this way of eating—be it keto or just regular ol’ low carb—the dramatic reduction in carbohydrate intake will be such a shock to your body that at first you’ll be able to “get away with” a higher fat intake for a while and it won’t interfere with fat loss. But eventually, things will settle down, and you might find that in order to mobilize the fat on your fanny, you’ll have to put a little less fat on your plate. It doesn’t mean you have to live on skinless chicken breasts, dry tuna, and fat-free cottage cheese, but it might mean that you have to lay off the fat bombs, bulletproof coffees, heavy whipping cream, and nuts & cheese (unless you’re really good about portion control with those last two, and let’s face it: most of us aren’t).   

Optimizing Health

What about people who don’t need to lose weight but are following this diet anyway, likely either because they think they need to lose weight, or because they think it will prevent weight gain, or because they’re simply trying to optimize overall health? Again, I’m not talking about cancer patients, diabetics, or those with insulin resistance, PCOS, or related conditions. I am talking about supremely healthy human specimens. As I have been emphasizing throughout this post so no one gets the wrong idea about what I’m saying here (even though some inevitably still will), if you are a supremely healthy human specimen following a super-strict KD and you feel like dynamite, great! Keep following it. But if you don’t feel so hot, perhaps it’s time for a change. If you’re following a particular diet for a particular reason—doesn’t even have to be keto; it could be anything—but success eludes you, then why continue to follow that diet? If a super-strict ketogenic diet is not getting you the results you want, then stop doing it.

You wanted to have more energy, not less, right? And you wanted to feel happier, not more depressed, right? And you wanted to feel more calm and stable, and less anxious, right? You wanted a better sex drive. In short, you wanted to feel good. But you don’t feel good. You feel lousy.

If you tell someone (or multiple someones in your forum of choice) that you don’t feel good on a very strict ketogenic diet, and they tell you you’re either doing it wrong, or you need to do it harder, please think about this same logic coming out of the v*gan community. Example: You have no energy, your hair is falling out, you haven’t had a menstrual period in 14 months, your joints hurt, you’re anxious, and your skin looks sallow? There’s nothing wrong with you; you’re just still detoxing from all your previous years of sinful and disgusting animal flesh consumption. You need MOAR KALE and MOAR CHIA SEEDS, and maybe a lemon juice & cayenne cleanse for your liver.

(This poor hypothetical anemic person needs a very large, very rare steak, STAT.)

Why stick with something that isn’t working for you, just because it’s working for someone else? As is true for disease prevention, following a super-strict ketogenic diet is not the only path to health, fitness, vitality, robust cognitive function, and a physique that others envy.

Robb Wolf doesn’t follow a strict ketogenic diet, and let me tell you, the dude is jacked.  Franziska Spritzler (“the low carb RD”) follows a low carb diet but not one that is strictly ketogenic, she does not fast, and she is slim, fit, and looks easily fifteen years younger than her real age (which I will not divulge out of respect for my friend!).  

All of this is to say that a ketogenic diet is not required in order to be slender, muscular, fit, strong, and healthy. You can keep blood sugar and insulin levels within healthy ranges without living exclusively on butter, coconut oil, kale, avocados, cream cheese, salmon, and mustard greens. I promise. You can be fat-adapted and be a “fat burner” without being in deep ketosis.

Low carb versus ketogenic:
When did “low carb” 
become passé?

I have had clients that were terrified—yes, terrified—to eat bell peppers. BELL PEPPERS. Because of the carbs! Can we please, please stop this madness? There is a world of vegetables and fruits that many people can consume and keep their blood glucose and insulin well within perfectly safe ranges. Not everyone is as metabolically damaged as others. Some aren’t much damaged at all. Maybe some people do need to avoid carrots, red and yellow peppers, red onions, beets, peaches, cantaloupe, parsnips, butternut squash, and tangerines—but that doesn’t mean everybody does. (If you think the “diabesity” epidemic was caused by people eating too many orange peppers or overdoing it on acorn squash or plums, you are [probably] WRONG.)

When it comes to carbohydrates, there is a continuum. Brightly colored bell peppers and yellow squash have more carbs than dandelion greens, but for the love of all that’s holy, they’re not exactly jellybeans! Am I making sense here? Any sense at all?

Before anybody gets the wrong idea here, allow me to explain myself.
When I tell people I think they might feel better eating more carbohydrate, I make it clear that I’m not suggesting those carbohydrates come from bread, bagels, pasta, fruit juice, granola, sugary corn or wheat cereal, or toaster pastries. (Not even organic, GMO-free toaster pastries.) They can come from larger amounts of the non-starchy veg these people are already eating, as well as a greater variety of vegetables. Things that had previously been completely forbidden, banished, and verboten. (Yes, I understand there are people who do need to limit their intake of carrots, yellow peppers, and the like, for the purpose of blood glucose control. I AM NOT TALKING ABOUT THOSE PEOPLE.)

This is why I continue to emphasize the distinction between low carbohydrate diets and ketogenic diets. As I’ve written about before, people use the terms interchangeably, but they are not interchangeable. Many people might feel (and look!) their best on a low carb, but not ketogenic, diet. As I have written about before, there’s a difference between being “in ketosis” and being fat-adapted. For the purpose of weight management (that is, maintaining a fat loss and warding off body fat gain), being fat-adapted is probably sufficient for most people. Maybe not all, but most. As is proven by billions of people around the world, strict ketosis is not required to keep blood glucose and insulin levels within healthy ranges, either. Some people need to maintain ketosis in order to achieve this, but that doesn’t mean everybody does. Many factors contribute to glucoregulation and insulin sensitivity, and individuals vary—like, really vary—in their carbohydrate tolerance. I don’t think anyone is necessarily suited to thrive on 300+ grams of carbs a day in the form of bread, cereal, muffins, cake, soda, and things like that, but there are plenty of people on planet Earth who can thrive on, say, 100-150g, maybe even 200g (remember, that’s still only 800 calories, which is not all that much for, say, a lumberjack, or someone else with a physically demanding job), coming from things like potatoes, parsnips, turban squash, beets, honeydew, taro, cassava, and grapefruit.  

First, just as people differ in their carbohydrate tolerance, people differ in what I’ll call their ketogenic threshold—that is, the amount of carbohydrate they can consume and still be “in ketosis.” (If that even matters!) The reason most of the popular low carb and ketogenic diet programs recommend starting off with 20--30g of carbs or less per day is because that’s the amount at which just about everyone will enter ketosis within a couple of days. But plenty of people can eat as much as 60g of carbs (if not more) and still stay in ketosis. That’s probably not the majority of people, but it’s some. (Again, I’m talking about inducing nutritional ketosis through normal dietary means, not exogenous ketones or extra-large servings of coconut or MCT oils.)

But what does it matter, anyway? What is the goal? Is it to be in ketosis, or to feel well? Is it to be in ketosis, or to lose weight? These are not synonymous. If you’ve been following a strict ketogenic diet with the intention of staying in ketosis at all times, ask yourself why. Why are you aiming to be in ketosis all the time, and are you achieving whatever goal you’re seeking? If perpetual ketosis isn’t getting you to where you want to go, why are you still doing it?

The great people at KetoGains have a saying: “Chase results, not ketones.” And if you join the Facebook group, you will quickly see that they get results.

Even the late, great Dr. Atkins, himself, never intended for people to stay in ketosis forever. The first two weeks is the induction phase, and that is 20g of carbs or fewer per day—for two weeks. He had what he called a “carb ladder” during the ongoing weight loss phase, or OWL. (OWL is the phase after the two-week induction period, but before someone reaches their goal weight and transitions into maintenance. It’s exactly what it says it is: ongoing weight loss, and while some people need to stay in ketosis in order to accomplish this, many don’t.) The carb ladder means that each week, carbohydrate intake is increased by about 5g per week until someone finds their individual carbohydrate limit for losing weight. This is the part many people don’t do. They stay in induction permanently, which is fine, if you’re happy there, you feel good, and you’re continuing to get results.

But if you don’t feel good, and you’re not getting the results you’re after, then for goodness’ sake, change your diet! Eat more carbs! Can I just say that already? For the love of all that’s holy, EAT MORE CARBS. You do not need to be in deep ketosis at all times in order to be lean, healthy, fit, and control your blood sugar and insulin. For healthy, lean, fit, athletic people, somewhere around 50-75 grams of carbs a day from hubbard squash, raspberries, tomatoes, yucca, or parsnips (plus your usual go-to greens and other very low carb vegetables) are not going to mean the difference between being a metabolic ninja or triggering a total health meltdown.

I’m sorry. I’m sorry I sound so angry. I’m just tired of getting emails from people who feel like garbage and are afraid to eat red peppers, but think it’s completely normal to put half a stick of butter in a cup of coffee. It gets old after a while, folks. I’m not the biggest fan of the Whole30 approach, but they do have some good stuff. This is what they call “the carrot train to crazytown,” and it’s worth reading.

If you think the presence of red onion and red, yellow, and orange peppers here means this gorgeous pile of delicious food could not possibly be acceptable on a ketogenic diet, please think again.

Back to my man, Dr. A. Just like I recommend for some clients, Atkins didn’t suggest people go up the carb ladder by reintroducing pasta, bagels, muffins, and biscuits. It was supposed to be larger portions of the low-carb vegetables they were already eating in induction, and/or reintroducing small amounts of the slightly sweeter items that were not permitted on induction, such as those carrots or red peppers. Induction is just that: an induction. An initiation. Maybe that’s what they should call it, in fact. An initiation. Because when you are initiated into something, there’s the initiation, and then it’s over. You’re part of it, and you don’t have to go through it again. It’s like fraternity and sorority hazing at a college, or basic training or plebe year in the military: the strictest, most regimented phase is temporary.

(I will acknowledge, though, that in the case of low carb diets, sometimes people do need to experience the induction phase a second time…or third or fourth, depending on how many times and how far someone has strayed from actually following low carb. Sometimes we do need to go back to the beginning. But most of us don’t need to stay there for all time. In this sense, we can think of induction as inducing the metabolic shift from a glucose-centric to a fat-centric metabolism.)


To sum up (for anyone who has actually made it this far):

Like I said in the fasting post: different goals might require different strategies. What are you looking to accomplish? Do you have cancer? Do you have Alzheimer’s? Have you suffered a traumatic brain injury? Do you have multiple sclerosis? Do you have PCOS? Are you trying to lose body fat? Are you an endurance athlete? Are you a powerlifter? Are you underweight and looking to gain mass? What is YOUR #context? The exact same dietary approach might not be suitable for all of these circumstances.

Again, this is absolutely nothing against keto. I love keto. Love it, love it, love it! When it is applied intelligently and rationally.

So, keep calm and keto on.
Or not.

I’ll leave you with the following gem from Bill Lagakos, PhD, who runs the excellent Calories Proper blog:

Myths: carbs cause insulin resistance (IR), diabetes, and metabolic syndrome.  Carbs are intrinsically pathogenic.  If a healthy person eats carbs, eventually they’ll get sick.

And the only prescription is more keto.”

Disclaimer: Amy Berger, MS, CNS, 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 and is not to be used as a substitute for the care and guidance of a physician. Links in this post and all others may direct you to, where I will receive a small amount of the purchase price of any items you buy through my affiliate links.