The Absurdity, Brilliance, and Snags of the Ketogenic Diet: Part 2

Welcome back to the ketogenic odyssey. After Part 1, you know what it is, the benefits, and contraindications. Let’s now discuss how to get into ketosis, signs of ketosis, and my concerns related to the ketogenic diet.
 
Getting into ketosis is not as easy as simply switching to Bulletproof Coffee for breakfast. There are various factors that hinder one from rapidly entering ketosis. For instance, an individual with a higher percentage of body fat will take longer to enter a ketotic state than a leaner individual.  Therefore, nutritional ketosis can take anywhere from 1-4 weeks depending on your body fat %, exercise regimen, stress levels, sleeping patterns, and chosen macronutrient breakdown. Be diligent, but patient with the process. The faster you slam into ketosis, the more painful your entry. More on that later. 

Choose Your Preferred Method
 
Your love of neurotic behaviors and numbers will determine if you want to execute this loosely or meticulously. Regardless, some type of tracking and self-experimentation is likely required to finesse yourself to success.
 
            Method 1: Simply track carbohydrate intake. Start at 60-70 grams of carbohydrates per day, which will possibly induce nutritional ketosis.  You can find the number of grams on any label or refer to an online resource for produce. There are plenty of useful apps out there for further assistance. If you’re not seeing the needle move, you can lower the carbohydrate grams slowly and/or decrease protein intake. This is likely a good starting point for most newbies.
 
            Method 2: Choose a specific ratio of carbohydrate/fat/protein. Unless you’re doing this for therapeutic purposes, immoderate ratios and calorie counting are unnecessary. Start with general percentages of approximately:
                                   Carbohydrates: 10-15%  (4 kcal/g)
                                       Protein: 15-20%  (4 kcal/g)
                                          Fat: 60-75%  (9 kcal/g)

---

Calculations for Easy Tracking:
Let’s say you established a daily caloric intake of 2000 kcal and a designated ratio of
10% CHO/15% Protein/75% Fat
 
The quantity of grams for each macronutrient is: 
Carbohydrates 10%: 2000 kcal multiplied by .1 = 200 kcal
Divided by 4 kcal/g= 50 grams of carbohydrates per day

Protein 15%: 2000 kcal multiplied by .15 = 300 kcal
Divided by 4 kcal/g= 75 grams of protein per day

Fat 75%: 2000 kcal multiplied by .75= 1500 kcal
Divided by 9 kcal/g= 167 grams of fat per day

---

​Extreme ratios or fast entry lends itself to undesirable side effects, therefore go slow or perhaps start with a Paleo-type diet. If you have a chronic disease, you may want to work with a functional professional that will help choose ratios that work with your body and disease state. For example, if you have kidney issues; an elevated protein intake may worsen your renal issue if not adeptly executed.  
​

How Do You Know You’re in Ketosis?

​Once you’ve selected a tracking method that works for you, how do you know you’re moving in the right direction? There are various indications of a ketotic state; however, possible discomfort may occur at the beginning due to dramatic alterations in the fuel supply. Think of these signs as annoyingly encouraging. 
 
The following are the most common signs of ketosis:

1. Elevated ketone bodies measured via blood, urine, or breath.
2. Bad breath. Acetone is one of the three types of ketones produced from the diet. Excretion of this fruity-smelling ketone is through the lungs, hence the Godzilla breath.
3. Decreased appetite.
4. Feeling worse before you feel better (see box below).  While your body is adapting to fat as the body’s main fuel source, you may experience fatigue, headaches, brain fog, and overall malaise which is endearingly termed “keto flu”. It is a temporary state and a good indicator you’re in ketosis.
5. Dry mouth
6. Constipation, diarrhea, nausea, and upset stomach.
7. Insomnia
8. Urine has a "funky" smell. Acetoacetate is another type of ketone produced that is excreted via urine and unique in scent. 

---

---

Fighting the "Flu"
The uncomfortable experience of the “keto" flu is minimized with adding electrolytes to your diet. The ketogenic diet is quite dehydrating because there are less carbohydrates to pull water into the system.  Therefore, electrolyte and fluid imbalances are super common. Try supplementing with potassium, magnesium, and sodium chloride (salt) daily. In addition, be quite liberal with water intake as the keto flu is typically due to rapid entry, dehydration, and/or electrolyte imbalances. ​

---

I am in the Keto Zone…Now What?
​
Integrating the diet successfully teeters on the daily, delicate dance between blood sugar and ketone levels. If ketones are too high, you’re in trouble. If blood sugar is too low, you’re in trouble. Put those two together at the same dinner table and you’re really in trouble. The absolute best way to do this is daily monitoring, but unfortunately people tend to “skip” this important practice and I would strongly encourage you to do otherwise.
 
The lower the ratio or grams of carbohydrates, the more important it is to adopt a daily monitoring practice. If you are unwilling to do this, then you need to back off or you will likely not feel well, and worse, possibly hurt your body over time.  
​

---

Monitoring Practices on the Ketogenic Diet
 
There are three methods to measuring ketones: breath, urine, and blood. The gold standard by far is a blood test. There are various high-quality meters available for daily use. Urine strips are easier and less expensive; but accuracy is highly influenced by hydration status. The breath test is the new kid on the block and at this point is quite expensive and does not outperform the blood test.  

---

Monitoring Goals:
Daily Blood Measurements Goal: Ketone range of .5-3.0 mmol/L.
 
Daily Urine Measurement Goal: Different urine strips vary with different brands but, in general, the darker the color indicates increased ketones. Remember, urine tests are sensitive to your hydration status so the results are only a rough estimate and rarely exact.

Daily Breath Measurement Goal: Ketone range from 4 to 30 ppm.

---

The more stringent you are with carbohydrates, the more important it is to use the blood meter. Regardless, you should be checking your ketones twice a day: morning and night to get a good idea how you’re doing with the diet. If you absolutely refuse daily, finger pricks, then you have 3 options:

1. Increase your daily carbohydrate intake to a minimum of 20% of total diet.
2. Start using urine strips or breath test to give yourself some clue as to effectiveness and safety of the diet.
3. Ignore everything I am suggesting.

 
You’re not going to like this next piece of advice, but you should purchase a glucometer as well. The number one mistake I see with the ketogenic diet is inadequate caloric intake. The diet often decreases hunger; therefore, people eat less. The problem with this is the blood sugars get too low. If you’re not feeling well, you need to check your blood sugars and ketones.  The solution is not to eat more fat if the ketones are high and the blood sugars are low. This common blunder simply dumps more ketones in your body. Remember, the no-fly zone is combining excessively high ketones with excessively low blood sugars. The solution is obviously to eat a small portion of carbohydrates. Don’t be afraid of doing so, as your brain cannot run on 100% ketones, and severe hypoglycemia is incredibly dangerous.
 
Best practices include daily monitoring of ketones and blood sugars. But, if you’re unwilling to measure blood sugars, at minimum, monitor ketones via urine. In this case, ignorance is definitely not bliss.

---

 
Laboratory Markers
​
I strongly advise you get baseline markers at the beginning of your diet and every 3 months until you get super savvy. The ketogenic diet is extreme. Don’t assume that your body functions perfectly and that everything is efficiently processed and extracted as intended. There are necessary enzymes and cofactors needed for proper macronutrient metabolism. The diagnostic list is long because safety (and effectiveness) are always my priority, but the basic assays to keep your eyes on are:
 
CMP (Complete Metabolic Panel)
Lipid Panel (Cholesterol, Triglycerides, etc.)
CBC with differential (Complete Blood Count)
 
I’ve seen cholesterol shoot up 200 points in less than 6 weeks from the ketogenic diet! Yikes. Flippancy and the ketogenic diet never belong in the same room; which is why I always encourage people to get help in ensuring the diet is done properly.
 
 Does this sound like a bunch of work? It is…and there’s more.

Snags of Going Keto

Let’s assume that you’re the perfect candidate for the ketogenic diet, you check your ketones diligently and adhere daily to the prescribed macronutrient ratio. Here’s where the diet may create problems:

• It’s one more diet that incites neurosis. I am a big fan of teaching people to integrate loose dietary guidelines that are diligently followed. The ketogenic diet is a serious commitment and will to some degree, create tension and negativity around food. Afterall, you are limiting yourself from a major food group that is woven throughout all worldly cuisines. It may induce disconnection between your culinary desires, body, and social dynamics; which is worrisome from a psychological standpoint. Obviously, it’s…. 

 

• Less than socially fun. Unless everyone goes “keto”, you may contend with family and friend interactions that could invoke feelings of separation, alienation, and loneliness.

 

• Microbiome Alterations. This is a BIG one. Copious research indicates the importance of a healthy gut, bacterial population. Fat and protein are extremely poor sources of fiber which is the main fuel for bacteria proliferation. Gut microbiome is constantly under assault with medications, toxins, stress, and poor food choices. You do not want to obliterate your microbiome further with a ketogenic diet. Going down that path will ultimately lead to chronic disease and ironically enough, weight gain. 

 

• Increased IGF levels (insulin-like growth factor) with increased animal protein intake. IGF is found in animal-based foods which are a major component of most keto-friendly diets. Research indicates increased IGF blood levels are correlated to increased risk of cancer and metabolic imbalances (1). Are you offsetting the benefits of the ketogenic diet by pumping your body full of molecules that induce oxidative stress and inflammation? Same goes for...

 

• Increased advanced glycation end products. These inflammatory molecules are known to increase oxidative stress and are predominantly found in animal products (see blog “Want to be Forever Young? Eliminate AGEs”). Bottom line: don’t sustain mostly on animal-based foods. Instead, think of yourself as being on a "Plant-ogenic Diet". 

 

• Increased protein intake. People on the ketogenic diet will often assume the diet is similar to the Atkins diet and increase their intake of protein for variety and satiety purposes. However, protein ingestion has an acidifying impact (at a cellular, not blood pH level) on the body that requires various, neutralizing mechanisms. Bone health is just one of the many arenas impacted, so watch your protein intake and stick to the designated protein percentage.

 

• Increases toxic load on the body. Most toxins are fat-soluble and stored in adipose tissue. Those toxins are directly released into the body when your fat stores decrease. Needless to say, I hope your detox system and liver are in marathon shape or you’re not going to feel well. How do you know? Genetics testing is super helpful but if you get light-headed from perfumes or get tipsy from alcohol easily, then you may want to pause before diving into the ketogenic waters. 

Which leads me to my next point…

• It may cause constipation. The decrease in fiber intake and dramatic alteration in fuel substrate will likely cause a plugged sewer. Toxins are released via bowel movements. If daily, large stools are not winding up in your toilet, you’re basically recirculating toxins. Again, don’t be surprised if the ketogenic diet doesn’t “agree” with you. (Pssst….now you see why I suggest getting assistance with all of this). 

 

• A stressor to your digestion system. All macronutrients require specific enzymes to break the big pieces into little, absorbable pieces. It’s highly possible that daily digestive enzymes are required for proper assimilation.  Focus on your daily stools for clues. Is the color, texture, or consistency different? Any changes are helpful in identifying if you’re actually absorbing all that fat you’re dumping into your body.

 

• Challenging diet adherence. Doing this diet well isn’t just about eating a boatload of fat faithfully. Food sourcing, supplementation, and quality of meals are key aspects of making this diet successfully healthful. Traveling extensively or a rocking social life may impair your ability to truly do this well. Picking out the tomatoes and prosciutto from a sandwich is ketogenic…but not necessarily healthy.

​

• Vitamin and mineral deficiency and/or imbalances.  With the exception of nuts, fat is not a rich source of vitamins and minerals, making you prone to impactful deficiencies.  Furthermore, carbohydrate substitutes in recipes tend to be in the form of nut flours which are a decent source of certain minerals. Minerals do compete with each other and create imbalances when one is eaten excessively over the other. For example, copper toxicity may occur if you’re not balancing it out with zinc-rich foods. It reaffirms why lab testing is so important. 

---

---

Bottom line:
A truly successful ketogenic diet involves tenacious awareness around specific metabolic parameters, fiber intake, micronutrient and electrolyte sufficiency, stress management, and proper nutrient assimilation. In addition, what’s your ability to remain faithfully relaxed around a self-imposed, restrictive lifestyle? Lastly, one has to consider the tendency for glut, animal ingestion. You really want to think of yourself as being on a high fat, plant-based diet with some elements of animal-based foods. The focus on plants will negate any unwanted compounds that naturally come with animal consumption. The hitch is to balance and integrate these issues without adding stress to your life. Stay tuned for my top suggestions on navigating the ketogenic diet healthfully. 

---

Resources:
1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3678929/