The Ketogenic or Keto-Adaptive Diet can be useful for many health conditions due its role in reducing inflammatory factors and AGEs formation, producing ketones which have epigenetic properties, regulating the clearing of old cells and regeneration of new ones. But before we get into it, did you know that the Textbook of Medicine in 1923 used a low carb diet to treat diabetes before the discovery of insulin and metformin? Well, not really the discovery of insulin as insulin was discovered in 1921 but didn’t make the textbook. But isn’t it funny that we’re going back a hundred years for treatment options.
Anyway, the ketogenic diet has to be done correctly as doing it half-heartedly can be more harmful to your health than not doing it at all. Two people I respect greatly in this line of work and certainly know more than I do are Marty Kendall and Alessandro Ferretti and the following information is based on what I’ve learned from them with some additions. If you need more specific information regarding the ketogenic diet I suggest you go to their websites. Here I focus more on other metabolic issues that may pertain to the ketogenic diet.
The following are some things to look out for with ketogenic diets which may affect the results you are going to get:
IS IT A TRUE KETOGENIC OR KETO-ADAPTED DIET?
This sounds very simple, but often people embark on ‘ketogenic diets’ which are not truly ketogenic but merely high fat. A true ketogenic diet is around 80% fat, 15% protein and only 5% carbohydrate. Many people eat too much protein or carbs and never get into ketosis. Around one third of protein eaten will enter gluconeogenesis. Remember, it’s the ketone bodies produced that provides most of the health benefits of ketogenic diets.
Eating high fat and too much carbohydrate/sugar will do tremendous damage to your body and may put you into ketoacidosis with elevated blood glucose and lipids, although this extreme is very rare in those who are not type 1 diabetics. The same thing with too much protein as this may also enter gluconeogenesis and push blood sugar up.
IS IT ENDOGENOUS OR EXOGENOUS KETOSIS?
Endogenous ketosis is dietary induced (via reduction of carbs and protein, and increase of fats) and considered very safe unless you have type 1 diabetes where more careful monitoring may be needed.
Exogenous ketosis is induced through external intake of ketones, MCT oil or amino acid supplementation. This has to be monitored with blood glucose as intake of ketones combined with high carb/sugar intake will create problems.
SO WHAT CAN I EAT?
One of the reasons I didn’t bother creating or putting up a food list is because there are already so many great ketogenic websites with amazing food lists, recipes and meal plans to choose from. My favourites are Marty Kendall’s Optimising Nutrition, Graig Clarke’s ruled.me and Dr. Steve Parker’s Diabetic Mediterranean Diet. But to give you an idea:
Carbohydrates: Mostly vegetables with low starch during the day and higher starch in the evening. Fibre from vegetables is important to keep the bowels moving and the microbiome healthy. There are different approaches, but in general it is recommended to start on 60-75g of carbs a day for 3-4 weeks if you are insulin resistant (high fasting blood glucose readings) and 20g of carbs a day if you are not insulin resistant (normal fasting blood glucose readings).
Protein: Meat, fish, eggs, collagen, high protein vegetables in portion controlled and not excessive amounts.
Fats: Grass fed animal products, fish, coconut oil, avocado, olive oils, nuts and seeds, eggs.
With the permission of Alessandro Ferretti I’ve included one of his sample menu’s to give a visual idea of what meals should look like below.
It may not be practical for some to jump right into a ketogenic-style diet especially if you are starting from a typical western junk food diet. So it’s perfectly OK to first transition to a Paleo-style diet and then from there, when you are fully committed, move to a proper ketogenic diet. Good resources to check out for Paleo Diets include Whole30, The Paleo Cure by Chris Kresser and The Paleo Primer by Keris Marsden and Matt Whitmore.
GETTING INTO KETOSIS QUICKER
One of the quickest ways to get into ketosis is to do some extended fasting, maybe for 2 or 3 days, or as long as you can go without food. It may not suit everyone, but can be useful in those who struggle to get into ketosis to begin with.
During this stage of no eating you can have some clear bone broths made from organic beef or chicken with sea salt to keep the electrolytes up. Drink plenty of water by sipping it slowly throughout the day and add some kombucha (fermented tea) in to keep the gut healthy. For extra energy you can add in beta-hydroxybutyrate salts or MCT oil for exogenous ketones. This will keep you in a ‘fasted’ state but minimize energy slumps and allow you to still get into ketosis faster.
The longer you have been in ketosis or the longer you’ve followed this approach, the quicker you’ll get back into ketosis, even after long breaks. The body becomes keto-adapted and uses cellular memory to flick the switch back into ketosis sooner.
Alternatively cut your daily carbohydrate content to 30g per day. If this is too hard you can eat up to 50g carbs per day, but it may just take you a little longer to get into ketosis. In order to stay in ketosis try and keep the carbs under 50g per day, but keep in mind other factors such as keto-adaptation, insulin resistance and exercise may make this different for everyone. Dr. Westman even recommends cutting it down to 20g of carbs for some people. In general obese patients with high BMI’s may be very carbohydrate intolerant and need to cut carbs quite drastically, maybe not initially, but eventually to get into ketosis. Something as simple as cooked carrots can spike blood sugar levels and there may be nutritional interventions that can help along in this instance.
CYCLICAL APPROACH TO KETOSIS
Some advocate for a cyclical approach to the ketogenic diet where every 4 or 5 days you take a day off and have more carbohydrates (more vegetables, sweet potatoes, rice and NOT sugar) or protein to kick you out of ketosis and then get back into the diet the following day. This can work quite well for those who can get into ketosis quickly, exercise a lot, and who are using it for performance or other purposes. It may not work so well for those who are insulin resistant and struggle to get into or stay in ketosis. It is however easier to get back into ketosis if you use more protein rather than more carbohydrates on your days off. You’d have to use measurements here and see what works for you as this is highly individual.
The most common electrolyte deficiency seen with ketogenic diets is sodium deficiency. This is because the drop in insulin secretion results in a drop in aldosterone and decreased salt retention in the body. This is beneficial for your blood pressure, but if you start getting cramps or headaches, increase your salt intake, especially if you do a lot of sports.
Adrenal function need to be supported before eating high amounts of fats. Cholesterol is important for the manufacture of hormones controlled by the adrenal glands.
People with chronic illnesses and inflammation may need to do this slowly and preferably under the supervision of a healthcare professional who truly understands the ketogenic diet and how it works biochemically.
Mitochondria need to work well to efficiently turn fats and carbohydrates from your diet into ATP or energy. Electrolytes and carnitine can be very useful here as well as B vitamins since grains (a big source of B vitamins) don’t really future on this diet. Two key enzymes, PDH (Pyruvate Dehydrogenase) and ACAT (Acetyl-Coenzyme A acetyltransferase), function as the entry point for fuel sources into the mitochondria and can be compromised by some infections, toxins, genetic mutations or nutritional deficiencies. Doing an OATS test gives us information on where blocks occur in the energy (citric acid or krebs) cycle and whether fuel sources are actually entering the mitochondria. This can be especially useful in those suffering from chronic disease or fatigue issues who are embarking on a ketogenic diet in order to improve their health.
A ketogenic diet can also improve mitochondrial function as glucose uses up a lot more energy and co-factors to go through the mitochondria to produce more energy whereas ketones only use 3 steps to produce energy and has great ATP-sparing benefits.
GENE REGULATION AND EPIGENETIC EXPRESSION
A lifetime of a high carb/sugar diet will upregulate genes involved in sugar metabolism and fat storage and downregulate genes involved in glycogen storage (GLUT) and fat burning. What does this mean? If your body is used to getting a lot of sugar and carbs then it will prefer to burn this for energy and NOT fat. If you eat more than your body can burn it will just float around, cause insulin resistance, downregulate GLUT (so it doesn’t go into the cells to be stored as glycogen) until the body finds alternate routes to break glucose down such as the glycation and lactate pathways which contribute to inflammation and disease.
The opposite is also true. If you start following a true ketogenic diet genes involved in fat burning and glucose storage (GLUT) will be upregulated and genes involved in sugar burning will be downregulated.
This epigenetic control can change quite quickly, but may vary from person to person. This could explain plateaus and why some take longer to see results. You may have to be patient for changes in gene expression. In essence you are retraining your body to burn fat rather than glucose.
GLUT4 RECEPTOR TRANSLOCATION
The better this works, the lower blood glucose will be and the quicker ketosis will happen. GLUT4 translocation is triggered by insulin and exercise mostly. Where insulin resistance or lack of insulin is a problem, exercise plays a more important role. Exercise can bypass GLUT4 translocation as well via a backdoor through the AMPK pathway, and inositol can improve insulin binding to its receptor improving its efficiency and reducing insulin secretion and resistance.
This means if you do intermittent exercise regularly (ie every 20 minutes, hour, 2 hours) you will keep these GLUT4 receptors open for longer and allow more glucose into the cells to use them up quickly so the body can switch to fat burning. I’m not going to go into much detail here as there are plenty of more knowledgeable authors on this subject than me, but I just wanted to suggest more ways to get into ketosis faster.
Keep in mind that genetic ‘snips’ is not just what you see on a gene report but can also be induced ‘snips’ through medications, environmental factors and nutritional deficiencies. These will alter gene function the same as a genetic polymorphisms through epigenetics. To be thorough I will mention some snips that may be of importance here.
- Because chronic inflammation can greatly influence the effectiveness and safety of a ketogenic diet, snips in IL, CYP, TNF may be considered.
- Antioxidant genes are just as important to protect against toxin release as fat is burned off and these include SOD, glutathione genes (GST, GSTM1, GSTM3, GSTP1, GGT1, GPX3, GSR, GSS, GST, G6PD, CGL)
- Mitochondrial snips include NQ01, SOD, and ADA blocks via arsenic are also important.
- Methylation genes such as MTHFR, MTR, MTRR and MAT.
- And off course lipid metabolism and mobilisation genes such as CETP, LDL-R, LPL, APOE, FTO, FABP2, FADS, ADIPOQ need to be included as well.
This really is just a snapshot in gene involvement and needs to be taken into context with other genes and environmental factors. I do not recommend focusing on singular genes as it will get you nowhere fast. But blocks in any of these (whether genetic or functional) or other genes may influence how effective a ketogenic (or other diets) may be for you, whether your body is suited to higher fat intakes at this point in time, or why you are hitting plateaus in your weight loss journey.
TYPE 1 DIABETES AND THE KETOGENIC DIET
There are differing opinions on whether type 1 diabetics should attempt ketogenic diets. I think it is certainly possible but will require some careful monitoring. One of the big risk factors for type 1 diabetics is the possibility of high blood sugar together with high blood lipids and ketoacidosis where both glucose and ketones are high. High blood glucose and lipids will predispose to heart disease and formation of AGE’s, rigid blood vessels, atherosclerosis, DNA damage and other chronic inflammatory conditions. Read Glucose Metabolism: Glycation and Methylation.
It is very important to check for any prior chronic inflammatory conditions with type 1 diabetics such as gut dysbiosis, lyme disease, viral infections or any other infections, heavy metal body burden, chemical exposure, environmental pollutant exposures, etc. Clean home, clean water, clean food, clean environment, clean air – all of this is very important.
Type 1 diabetes is an auto-immune condition involving the destruction of pancreatic ß-cells, so it is very likely that there will be mitochondrial dysfunction going on that needs to be addressed as well.
PREGNANCY AND THE KETOGENIC DIET
It is not recommended to start a ketogenic diet while you are pregnant. Remember that as you burn fat more toxins will be released into the bloodstream which is not what you want to be doing during pregnancy. However, we have not found any evidence that ketones itself are unhealthy for the unborn baby, so theoretically someone who has been on a ketogenic diet for a significant period of time, are already in ketosis and have already gone through the ‘detox’ period may be OK to continue with the diet during pregnancy with modifications to include more vegetables. This HAS to be closely monitored and all health professionals involved should be made aware of this and preferably be on board to make sure all nutritional requirements are met.
We are not advocating the ketogenic diet during pregnancy, merely sharing some thoughts.
MEASURING BLOOD GLUCOSE
It is recommended to start with measuring your fasting blood glucose levels first especially if you are insulin resistant or suffer from metabolic syndrome, type 2 diabetes, etc. Once fasting glucose readings are stable and consistent start measuring urine or blood ketones. Tools to measure glucose readings include Precision Xtra or Freestyle Optium Neo. Accu-chek is another good glucose monitor.
There are various methods to measure ketones (breath, urine, blood) and they all can be used but provide different information. Breath ketones (acetone) will be higher in the morning and after exercise because it measures the ‘spend’ or ‘exhausted’ ketones. You can measure acetone with Ketonix. Blood ketones (β-HBA) are more dependent on food intake and reflect ketone reserves. Urinary ketone (acetoacetate) sticks are useful to measure when you get into ketosis and even for a couple of weeks, but not the best method to keep monitoring it as it only reflects the ketone ‘spilage’. After about 2-4 weeks most people become keto-adapted and start using ketones very efficiently as an energy source. This is when acetoacetate is converted to β-HBA in the blood and the urinary ketosticks will no longer turn purple. Urinary ketones are also a bit slower to show than blood ketones, so blood levels will always be higher than urinary levels.
Ketones will be lower first thing in the morning due to low reserves but will generally rise after 1-2 hours. If you do baseline checks make sure you measure it at the same time every day. If you want to measure the effects of foods/drinks on ketosis then you can measure throughout the day.
The best method seems to be looking at the ratio between ketones and glucose. The closer the ratio is 1:2 with ketones:glucose, with the ketones at least half of the glucose (when measured in mmol/L), the better.
For measuring blood ketones (β-HBA) Jimmy Moore recommends using Precision Xtra or Freestyle Optium Neo over Nova Max as Precision Extra can measure extremely low levels of ketones and still give you a numerical value. Here is a link to his side-by-side comparison. I personally have not used either of these so cannot give an informed opinion myself. Whilst the keto-devices are not that expensive, the strips will set you back quite a bit especially if you want to monitor levels regularly. Jimmy provides some helpful tips in how to get the best price when buying the keto-strips.
General measurements to aim for:
Urine ketones: >15mg/dl
Blood ketones: 0.6-1.0 mmol/L in the morning, 1.0-3.0 mmol/L during the day
Breath ketones: >45 with ‘ketonix’
MEASURING HEART RATE VARIABILITY
The higher your heart rate variability (HRV), the better. HRV will generally go up as inflammation decreases and ketogenesis increases. This is because HRV is regulated by the autonomic nervous system.
The sympathetic stress response and ketoacidosis will decrease HRV.
This is just another useful measuring tool to monitor how stress affect ketosis and degree of inflammation. Companies like Firstbeat uses data collected from heart rate monitors to give personalized insights on stress, exercise and sleep. Other HRV monitors include Polar H7 and Armour. HRV apps include HRV4Training iOS, iThlete iOS/Android, EliteHRV iOS/Android, HRVLogger iOS and Stressed Out iOS. Optical wrist monitors are not very reliable in their readings.
You can also go to DC Rainmaker if you want more in depth reviews on devices measuring performance.
If you need guidance in the treatment of this or any other condition, please make an appointment with one of our practitioners.
This article is for information purposes only. Please refer to our Medical Disclaimer policy for more information. The opinions expressed here represents the author’s and not necessarily those of Realize Health. In addition, thoughts and opinions change from time to time due to updates in research and as a necessary consequence of having an open mind. Views expressed in out-of-date posts may not be the same to those we hold today.
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