Adverse Reactions to Ketogenic Diets: Caution Advised

May 6, 2015 in Categories: , by

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As the ketogenic diet gains popularity, it’s important to have a balanced discussion regarding the merits of this diet. Let me emphasize right out of the gate that this is not a diet without merits (excuse the double negative); in fact, it has significant therapeutic potential for some clinical pathologies. However, it is also a diet with inherent risk, as evidenced by the extensive list of adverse reactions reported in the scientific literature—and this has not yet been a thorough enough part of the public discussion on ketogenic diets.

keto macros

Typical ketogenic diet macronutrient ratios

This is the first of a series of articles discussing various facets of a ketogenic diet with an inclination toward balancing the discussion of the pros and cons of this high-fat, low-carb, low/moderate-protein diet. My interest in this topic stems from concerns I have over its general applicability and safety, simultaneous with its growing popularity. I feel a moral and social obligation to share what I understand of these diets, from my perspective as a medical researcher. The dangers of a ketogenic diet was, in fact, the topic of my keynote presentation at Paleo F(x) this year (links to video will be provided once available). This series of articles will share the extensive research that I did in preparation for this presentation, including all of the topics covered during my talk as well as several topics that I didn’t have time to discuss (also see the free PDF Literature Review at the bottom of this post).

For every anecdotal story of someone who has regained their health with a ketogenic diet, there’s a counterpoint story of someone who derailed their health with an identical diet. I’m not here to trade anecdotes. I’m here to cite a collection of scientific papers, including results from clinical trials, case studies, and mechanistic studies that show a potential dark side to the ketogenic diet.  And that dark side is one that everyone needs to be aware of while they perform their own individual cost-benefit analysis to decide whether this dietary strategy is worth attempting for them.

Where Do Ketogenic Diets Come From?

The origins of the ketogenic diet were the observations of Hippocrates in 500BC that fasting could reduce and even cure epileptic seizures (fasting is also a ketogenic state, more on that in a future post). However, it wasn’t until 1911 that the first scientific study on starvation as epilepsy treatment was published. Two French doctors, Guelpa and Marie, observed that a 4-day fast decreased seizure frequency in 20 epileptic children and adults, which led to “La cure du Dr. Guelpa”, a prescribed treatment for epilepsy that consisted of fasting followed by a very limited vegetarian diet. Dr. Hugh Conklin popularized fasting (three days to three weeks) as a way to cure numerous illnesses, including epilepsy. The banner was taken up in 1921 by endocrinologist Dr. H. Rawle Geyelin, who was the first to document cognitive improvement resulting from fasting in a scientific study performed on 26 epileptic patients.

fasting as cure for epilepsy

Dr. Conklin’s work hit the news!

Fasting has one very important barrier to rampant clinical use: it’s not sustainable. You can’t starve for the rest of your life and expect it to last very long. In 1921, Drs. Stanley Cobb and W.G. Lennox became the first to observe that control of seizures by fasting occurs via a change in body metabolism that can be induced either by absence of food or by a very low carbohydrate intake. And this observation led to the birth of a form of nutritional starvation, the ketogenic diet, a term coined by Dr. Russell Wilder who developed the diet as an alternative to fasting and demonstrated its comparable effectiveness in epilepsy. Dr. Wilder observed that the diet produced high levels of ketone bodies in the blood and hypothesized that a high fat, low carbohydrate diet would mimic the anticonvulsant effects of fasting because limited glucose supply would force fat to be metabolized into ketones, which could then be used as an alternative fuel by the brain (this hypothesis took decades to prove, and the more detailed mechanisms remain largely a mystery). In 1925, Dr. Mynie Peterman, calculated the exact formula for nutritional ketosis, a daily diet comprised of: 10 – 15 grams of carbohydrate, 1 gram per kilogram of bodyweight of protein, and the rest fat (a macronutrient formula that is still within the narrow range used in various ketogenic diet variations today) . In the earliest epilepsy studies, calories were restricted to 75% of daily allowance, although the need for calorie-restriction concurrent with ketogenic diets for the treatment of epilepsy has since been disproved.

Research into ketogenic diets went through many ups and downs over the decades that followed. Every time a new anticonvulsant drug for epilepsy was developed, interest in ketogenic diets waned under the presumption that it’s easier, and more tolerable, to take a pill every day compared to a severely restrictive diet. However, interest was rekindled in the wake of professional and public recognition subsequent to: the popularity of the Atkins’ Diet Revolution; a Dateline report featuring a 2-year-old Charlie Abrahams whose intractable seizures are successfully stopped after he adopted a ketogenic diet; the creation of The Charlie Foundation which disseminates informational ketogenic diet videos to doctors and dieticians; and the movie Do No Harm. Since the late-1990s, research into ketogenic diets has expanded, including a series of long-term ketogenic diet studies for refractory epilepsy (epilepsy that did not respond to anticonvulsant drugs) and investigation of a variety of other applications such as weight loss, tumor shrinkage, and neurodegenerative diseases like Alzheimer’s.

Adverse Reactions to Ketogenic Diets

As the list of health conditions that may be at least partially alleviated by ketogenic diets increase (and which currently includes epilepsy, Alzheimer’s, Parkinson’s, Autism, traumatic brain injury, bipolar disease, PCOS, cancer, obesity, and diabetes), so too does a body of literature pointing to common side effects and potential adverse reactions.

Adverse reactions to a ketogenic diet have been reported in the scientific literature. Yes, even including well-designed clinical trials performed and published very recently.  In fact, the intolerability of side effects and adverse reactions is the primary reason for trial participants to drop out of clinical trials (other reasons for trial drop-outs include ineffectiveness of the diet, and that the diet is too hard to follow).

Adverse reactions are not the same thing as side effects.  An adverse reaction is an, unwanted/unexpected and dangerous reaction to a therapeutic agent.  In contrast, a side effect is a secondary, typically undesirable effect of a therapeutic agent.  More simplistically, side effects are minor and adverse reactions are not. Side effects are typically what are reported in shorter-term studies, where as both side effects and adverse reactions are reported in the long-term ketogenic dietstudies (typically 6 months to 2 years, but any study that allows for keto-adaptation, which takes up to a month, can be considered long-term).  This article is not a discussion regarding side effects, the list of which has some overlap with the list of adverse reactions (for example common side effects include minor gastrointestinal symptoms).  This article is to draw attention to the documented adverse reactions, which include:

  • Gastrointestinal disturbances (diarrhea, vomiting, nausea, constipation, GER)
  • Inflammation risk
  • Thinning hair/hair loss
  • Kidney stones
  • Muscle cramps or weakness
  • Hypoglycemia
  • Low platelet count
  • Impaired concentration/cognition
  • Impaired mood
  • Renal tubular acidosis
  • Nutrient deficiency
  • Disordered mineral metabolism
  • Poor growth in children
  • Skeletal fracture
  • Osteopenia/osteoporosis
  • Increased bruising
  • Sepsis, infection, bacteria overgrowth
  • Pneumonia
  • Acute pancreatitis
  • Long QT intervals
  • Cardiomyopathy
  • Shift towards atherogenic lipid profiles (including hypercholesterolemia and hypertriglyceridemia)
  • Heart arrhythmia
  • Myocardial infarction,
  • Menstrual irregularities and amenorrhea
  • Death

That’s a long list. A long list of not-good things. And did you can’t that last one? Five scientific papers have reported deaths as an adverse effect from long-term ketogenic diets (here’s the citations: Stewart, et al., 2001, Kang, et al., 2004, Kang, et al., 2005, Bank, et al., 2008, Suo, et al., 2013 and make sure to check out the free PDF download of my Literature Review at the bottom of this post which contains details on all of the papers reporting adverse reactions). Two of these papers are case studies, and the other three are papers derived from two separate clinical trials, all studies in epileptic children. Some of the deaths can be attributed to extra complications from secondary conditions or accidents that befell the child during the course of the clinical trial; however, other deaths—most typically from severe infection or heart disease—are attributed directly to long-term ketosis.

The Relevance of Adverse Reactions

I believe the potential for adverse reactions is important information for people to know when they are weighing a ketogenic diet versus other diets or therapeutic options. But, that doesn’t mean that everyone need avoid ketogenic diets. It’s a question of weighing the pros and cons for each individual.  And certainly some of the above adverse reactions can be prevented with careful choice of foods and/or targeted supplementation (such as nutrient deficiency).  And it’s important to emphasize that the above list of adverse events also points to a long list of tests that can be performed regularly by a supervising health professional to monitor for any potential detriment in the event that there are compelling reasons to undertake a ketogenic diet.

fatty foodsWhen you read reports expounding on the benefits of a ketogenic diet, purporting that there is no risk involved or at least no risk for most of us, the origin of this dogma is either a selective reading of the science (which may be unintentional—I’m not a conspiracy theorist) or a bias-motivated dismissal of any scientific studies to the contrary of this narrative.  For example, I’ve heard these adverse reactions described as “minor” and “transient” or attributable in some way to “people doing keto wrong”, statements that are not actually substantiated by the scientific literature (although, those might be fair appraisals of side effects from short-term studies).  As a second example, I’ve heard declarations that the long-term ketogenic diet studies in children with refractory epilepsy are irrelevant since these children are not robust, heathy kids and many of them (although certainly not all) are simultaneously taking anticonvulsant drugs while following a ketogenic diet to mitigate severe, frequent seizures. Because the overwhelming majority of the long-term ketogenic diet studies have thus far been performed in the context of epilepsy, this is the field of research that has most thoroughly reported adverse reactions. Certainly, these kids belong to a more sensitive population (why documented deaths as a result of adverse reactions to a ketogenic diet have occurred almost exclusively in epileptic children), but that doesn’t mean that these reports don’t provide extremely useful information, or a warning worth heeding (another double negative!). After all, it’s not typically the robust healthy person who experiments with ketogenic diets to improve their health—and while death is probably very unlikely, the potential harm to other body systems (cardiovascular, immune, endocrine, digestive) remains.

The Need For More Science

The body of scientific literature on ketogenic diets is surprisingly sparse when you consider the therapeutic applications of this diet have been in effect for nearly a century. A mere 1592 scientific papers are returned by PubMed (the US National Library of Medicine and National Institutes of Health online medical research database) with the search term “ketogenic diet”. It’s not that other diets are more thoroughly researched per se, but certainly other therapeutic strategies to mitigate disease, the most relevant example being anticonvulsant drugs for epilepsy (c.f. PubMed returns 135282 scientific papers with the search term “anticonvulsant drugs”) are monumentally better understood before being approved for use.

Frankly, research is just beginning to scratch the surface in terms of understanding how ketogenic diets work to reduce seizures in epilepsy or to provide the other documented benefits. Why is that important? Because the extensive list of documented side effects and adverse reactions indicate that the positive health effects of a ketogenic diet comes at a cost, one that may not be acceptable to many. Understanding how a ketogenic diet works to provide a benefit, also gives clues as to why it causes adverse reactions. And because the documented adverse reactions include serious illness and death, understanding why these might come about is a prerequisite for adopting this therapeutic strategy in a more widespread way. What insight we can glean from mechanistic studies will be the topic of several future articles.

Does the need for more science give ketogenic diets a green light or a red light?  I certainly agree with the ketogenic diet community that more long-term and mechanistic studies are required.  However, I disagree that, in the absence of the insight this research could provide, that everyone should just “try it for themselves”.  We need to look at the information currently available for guidance.  The studies do not ubiquitously show benefits; not everyone responds positively to a ketogenic diet; many unanswered questions regarding the effects (both positive and negative) of ketogenic diets remain; serious adverse reactions have occurred.  As a community, we have a choice:  proceed with great abandon, or have a more nuanced and accurate conversation of what we know versus what we don’t know.   I support the latter and believe the capacity for harm needs to be just as much a part of the conversation as the therapeutic potential.

The Fine Print

Other diets do not trigger the same biochemical pathways that are activated by a ketogenic state. And while certainly other diets (Paleo, or the autoimmune protocol being good examples) stake therapeutic claims, the mechanisms of action are purely through micronutrient saturation and avoidance of foods known to be inflammatory. The ketogenic diet is different in that it was designed to emulate starvation, taking advantage of the biochemical benefits of starvation for certain body systems (mainly neurological, but this is also why weight loss is a common result of a ketogenic diet) while tolerating the detriments to other body systems (such as endocrine and immune systems). (These are even different mechanisms that a standard low-carb diet.) In this regard, the ketogenic diet more closely resembles a drug than a diet (in fact, many of the same pathways activated by a ketogenic diet are manipulated by anticonvulsant drugs), which should not be a deterrent in itself, but rather a caution to read the fine print and talk to your doctor before embarking on this course—especially if going “off-label” and using a ketogenic diet for purposes that have not yet been well studied. And this is why a thorough understanding of both the pros and cons of a ketogenic diet are necessary in order for every individual to make the best decision for themselves.


Keto Infographic

Citations and Additional Reading

Keto Download Preview

This PDF contains a review of the literature on ketogenic diets.

Normally, my science-based posts contain a dozen or so references at the bottom.  This post is special. With the help of the sagacious Denise Minger, author of Death by Food Pyramid, I have compiled an review of the literature, with a particular focus on the studies that report on and potentially explain the mechanisms behind adverse reactions (there are plenty of reviews available on the internet reporting the documented benefits).  This review also includes links to original publications and summaries of over 80 scientific papers that I read in preparation for writing this blog post, the future posts that I’m working on in this series, as well as my Paleo F(x) 2015 talk.  Download this free PDF here.




I dont want to be rude. But many people eat terrible food. Full of refined carbs and other rubbish. Then they cut out carbs eat real meat and get results lol. Keto def seems to be good for some and for treating ailments. I think there is enuff evidence. But does it really beat my gameplan? Well balanced diet with super veg, strength training and some cardio? I feel great i have cheat meals I enjoy my food. Why wud I give that up? I love my metabolic rate…I love my body saying foooooood mmmm. I love eating 5 to 6 times a day. Why wud I remove an entire food group? I use carb cycling between .5 and 1.5 grams of carbs per day depending if Im trying to lean out or build muscle. It just seems that keto is an excuse for many who try to sit on thr bums but they still wana lose weight. Then they claim to be full of energy? What does that mean? Energy to get thru the day? Thats not energy hehe. Running a new pb over 100m or crushing ur next game.

I have been keeping track of what I would not be able to eat or drink that is proven by science to be beneficial for ones health.
1.beet, carrot, apple and ginger juice. Fresh made organic. 1 of these would prob put me out of keto. I have decided not to try a keto for my next lean out phase. I just dnt see the merit right now and its just too restricted. The premise of cutting out things just because they will keep u out of keto just doesnt seem sensible at this point.
I think my juice is about 50gr of carbs about 2 glasses. Also taken daily i notice increased strength and a viagra effect.

Keto’er here.

I have to say, you’re doing a great job of espousing last century science here about Keto. I would suggest you do a bit more research and look at some of the more recent studies in this area. What I just read is something I would expect from a dietitian trained in the 1990’s.

Thank you for this, I couldn’t agree more. I’m a T1 diabetic and eat less than 30g per day, although ketosis isn’t my goal, I am almost always in keto. My bloodsugars are better than most non-diabetics, my A1c is 4.8 and I take about 30-35u of insulin per day. After being diabetic since age 6, close to 30 years, it’s not a matter of if but when complications will set in due to elevate bloodsugar. Diabetics can’t process carbs, were carb intolerant. So it’s necessary to cut them out to maintain control. Some don’t realize this or choose not to, and that’s okay, but this “scientific post” is damaging to those who are considering cutting out carbs in order to gain control over their health to avoid blindness, kidney failure, heart disease, loss of limbs… Definitely disappointing. I hope the science wasn’t cherry picked and it was a true oversight.

Lol, so instead of listening to a qualified dietician, we should listen to some random guy on the internet who talks about studies but doesn’t provide them? The cult like attitude of keto dieters is all I need to see how bullshit it is. Anything that attracts such snowflakes is suspect.

I’m a Type 2 Diabetic who has been on the ketogenic diet for 2 months. My blood sugars have been amazing, but I’ve always wondered why you don’t often see anything about long-term negative side effects of this diet. Clearly high blood sugars also have long term side effects, but it’s hard for me to weight high blood sugar (which I see immediatly when I increase my carbohydrate load) and the effects you mention in this article. This has given me a lot to think about, thanks so much for all the hard work you’ve put into the research and writing. It’s great to read information from people in this community who actually have the scientific training to back up their writing.

I know folks who have eaten this way for many years and who are extremely healthy and fit. No worries about long term effects here (other than excellent health!)

There are risks for any life style or diet and yes there are reasons to consider temporary cycles of mild ketosis and non ketotic states. However I do want to point out that several of the potential “side effects”/problems that are mentioned are directly linked to sodium/potassium balance and a lack of minerals/vitamins and arguably fiber. If someone does a “well-structured” ketogenic diet, gets plenty of green leafy veggies, minerals and a good sodium/potassium balance many of those issues will be avoided.

There could easily be a case/article pointing out living on a glycolitic metabolism 24/7, 365 for many years has much higher risks.. For major diseas known to society today.
I agree am argument can be made for cycling one metabolic states.. And perhaps following a seasonal approach.. But I feel this article is looking for a reaction is isn’t entirely accurate about the true risks.

I agree 100%. Whole foods well formulated KDiet. Ive been on keto for 7months now and the only issues I had were from the addaptation to it.

From the reading of the studies above it seems to me that diets were
only based on macro nutrients rather than focusing on the micro ones.

I have been in ketosis for 30 years due to pre-diabetes. I am 56, I am at my perfect weight (120 pounds) and I have NO medical problems. My cholesterol is low and my doctor says I have the blood pressure of a 16 year old. All those things on your list, I know people who have been cured by them eating a ketogenic diet. And as far as “death” goes, there is no diet that can prevent that. Alzheimer’s is caused by the hippocampus being starved for cholesterol. Then it dies and triggers the domino effect of Alzheimer’s. I learned that from Alzheimer’s Solved by Dr. Henry Lorin. I cried when I was told by my doctor that I could not have any more carbs. I said I would rather be blind and deaf. It changed my life so much that I could kiss his feet. Ketosis is the Fountain of Youth. You need to try it for a month before you put it down. One week to get into ketosis, one week to get the hang of it, and the two weeks of increased mental and physical energy, while you don’t have any more hunger and cravings, you eat until you are full, and the fat comes off and your muscles grow even without exercise. And your health problems evaporate. I know it sounds “too good to be true”, but it works for everyone on the keto forums. It will work for you too.

Your “Dr. Lorin” is a fraud. The cause of Alzheimer’s is still unknown. The cause is believed to be a combination of intrinsic (eg. genetics) and environmental factors. Pretty sure “Dr. Lorin” would’ve won a Nobel prize otherwise.

Nutritional ketosis has changed my life. I don’t care what you say or what “data” you have, my experience with it has been wonderful and I was paleo before nutritional ketosis. For me there is no comparison.

I was very disappointed reading this article. Either your sources are false or you haven’t researched a Ketogenic diet. Ketones actually reduce inflammation – they do NOT cause inflammation. I have been using a Ketogenic diet for 7 years. I have lush thick hair, I’ve rid my body of mycotoxins and yeast and I have been symptom free from multiple sclerosis for many years now (and take no meds). Many studies are on the rise using this diet to treat autoimmune diseases (like Terry Wahl’s). And I do not feel deprived eating delicious food full of fat and butter. Occasionally I miss fruit during apple picking season but being able to walk and run again far outweighs a piece a of fruit.

Okay quick scan of the list says keto causes Pneumonia? Seriously? A germ causes it. Bacteria/viral/and even possible Fungi. Now, if you can not even get THAT bit correct..I am completely not accepting the rest of your statement as factual.
– ALL my (36 years of) IBS problems stopped COMPLETELY. Seriously the difference is astounding. I never thought that I would go through life without the crippling symptoms that I had experienced for so long.
– T2 Diabetic. Off all meds and A1C dropped from a 10.8% to a 5.0% ..and I expect even lower next visit.
Reduced blood pressure…inflammation..blood sugar..improved lipids..liver enzymes..every single lab result has improved Dramatically. My physician practically does cartwheels in excitement over my results.
(BOTH my GYN and my previous Cancer surgeon(highly renowned in her field University Hospital systems) recommended Keto as prophylactic protection against many issues that they treat.).

I think that I would like to read the references(and dates) on this chart’s “bad” list.

Think for a moment, about the sheer impact, of the idea getting out, that fasting -or even eating less all-around, would have on the food industry.. Anyone freed from the addiction of carbs/sugar, knows the grip of it and is reluctant to go back to it thoughtlessly; trimming the calories happens effortlessly, fasting is no longer a feat. This is a huge detriment to the food industry and and even bigger problem for Big Pharma.. Married to the government, corporate fascism is where america’s nutritional guidelines are derived, From the ‘feed” type foods; grains as the basis of our diet pyramid to “Breakfast is the mo$t important meal of the day”! and the disease that springs from it, is coddled till death with a pill for every condition ….five studies you say? That’s not a drop in the bucket for these moguls to buy.
Today it’s safe to say, that any subject of science to be peer reviewed, -and is going to involve A LOT of money; is already bought and sold.. …it’s up to each one of us to be more speculative and discerning than ever

hi, Dr. Sarah… there is a path way for each and everything that happens inside the body right? So.. will you please explain the pathways for each and every adverse effect of ketosis that you have mentioned above. thank you

You can do some research as well. I specifically researched regarding bi polar and discovered losing sodium on the diet mimics what anti convulsants do (which are typically given to bi polar patients) so the info is out there.

That’s ridiculous, “Human” – low sodium is not a symptom of a ketogenic diet. It’s a symptom of not eating right. I used to have low sodium levels on a high carb diet. Now that I’ve learned a bit more about my body’s requirements, my sodium levels are fine – ON a ketogenic diet.

AIP helped me with many symptoms, but it wasn’t until I did AIP AND keto at the same time did my inflammation completely go away, my brain fog cleared, my blood sugar regulation issues disappeared, morning nausea and sudden hunger disappear and I finally felt good again. I was eating too many carbs to feel well on AIP, about 100 grams a day, due to having butternut squash and sweet potatoes throwing off my blood sugar.

I continued to have severe brain fog and digestive issues on AIP that I don’t have on AIP plus keto, and I do not test as allergic or intolerant to any of the AIP foods I was eating.

I’m currently transitioning into Wahls Paleo Plus, a ketogenic diet along the same lines as AIP, and I’m doing great. I’m getting 10-15% of my intake in carbs a day from AIP-approved vegetables in the proportions Wahls recommends, yet still losing weight and having my auto-immune symptoms decrease while I stay in ketosis. It’s working for me, and I’m so happy I moved away from AIP and towards keto and Wahls because my health has only improved from it.

AGREE! I was Paleo then AIP for Hashimoto’s (had it for 20 years). I then went AIP Keto and amazingly things are starting to even out. I also was eating too many of allowed carbs and having the same issues – carb cravings, brain fog, depression, anxiety, no weight loss and the endless cycle of junk.

I basically eat vegetables, protein and fats (more fats) – (and track my food) with a treat of berries every now and then. Perfectly happy. Oh, and I work out intensely 10x per week (because I want to and can!), have a trainer and have been doing this for 5 months with no lack of energy, no crashes and plenty of power. Sleeping perfectly, loving my food and feeling so much better.

The replies just prove again: The key is not to invent the perfect diet but to just find the right diet that fits to your personal biology! The same diet can be healing for one person and inflammatory for another. It´s the same with every singe diet / macronutrient composition! I now have read SO many contradictory experiences from the same diets that I´m now a firm believer in the different metabolic type theorie. It´s all about finding where you are at the spectrum! Plus some details concerning food intolerances and allergies. And don´t forget environmental factors, for me it was mold… I wish everyone well on his journey! Just stay open to the signals of your body, it´s needs can slightly change from time to time.

This is completely irresponsible. I have been on a 35 carb Paleo (no grain period) KETO way of eating for years. I no longer have chronic bronchitis, my moods are quite balanced. After years of yo you dieting I have maintained my best weight EVER with no effort. This is a wonderful way to live not ever DIET again. Please do not take this fear mongering article as gospel.

It’s a shame that you don’t put your physics degrees to better use, Sarah. You really do have a lot of great information but I feel you could use your physics background to much better use.

If you looked into this issue from a physicists perspective you would understand that food = electrons & protons.

To be called The Paleo Mom and to say ketosis could be bad is just contradictory. Paleo people did not eat carbs in the winter. They would have been in ketosis most of that season. Then carbs were slowly ramped up during Spring and Summer as increasing photons from the sun permitted.

Ketosis is a temporary tool to be used seasonally.

Ketogenic diets can be dangerous if not administered correctly, but not everyone adheres to the same plan. Finding the right balance is key. A good ketogenic diet includes both eggs and avocados, and avoiding the temptation to go for an overkill of nutritionally empty fat calories. Try to consume under 1500 calories per day, but at least 1000 calories per day. Make sure your body is adequately hydrated, but not over-hydrated either (the best clue on this is the color of your urine, rather than an actual water intake guideline). Do not consume more than 60% of your calories from fat. Seek nutrient dense foods as your carbohydrate choices which should account for ~15% of your calories and choose high quality animal protein for about ~15% of your calories. The remaining calories should be complete proteins from plant sources and light snacking, as needed to make the diet easier for you. Contrary to popular belief, it is OK to have some fruit—but make it healthy by being high in fiber and low in sugar like raspberries.

Overall, if you have found the right balance, your body will tell you the rest. You won’t even want to look at bread—you’ll throw it out. You’ll find that you are NATURALLY consuming an appropriate amount of sugar without any struggle. You will avoid foods that are not filling or being absorbed appropriately by your body. The only real downside for the diet is if you are an athlete, as it is hard to make the diet work for such a person. But I firmly believe that losing those extra pounds first is the priority. Once you are down to a healthy weight THEN you can find another diet that is suitable for an athlete. Exercise will do NOTHING but make you more hungry if your diet is terrible. So you have to prioritize which to fix first.

I really cannot thank you all nearly enough. As a 52 year old battling breast cancer, I have been on a ketogenic diet for 5 days now. Prior to my double mastectomy, I was on it as well – AND THE INFLAMMATION WENT DOWN. Is Dr. Sarah seriously a physicist? Sheesh! OK, anxiety levels have backed down after having been sent this link by a family friend. I’m so happy to hear of everyone’s results – I KNOW this is the way to go; it’s the one thing I can control. Thanks again for those of you looking at this article with a critical eye…..

Hopefully the linked studies contain more meaningful detailed information about the composition of the ketogenic diets studied. This article does not summarize that aspect at all. (Maybe future articles do, but I would like to see something pointing to that information, an indicator of its importance.) Like all observations re the impacts of diet, results depend on the context and specific composition of the diet. For example, what were the animals fed – were they factory farmed or grass-fed? That affects the composition of the animal fats consumed, which would affect the outcomes listed. Also, a ketogenic diet that focuses on animal foods and fat and keeps vegetable intake low is not the same as a Wahl’s style protocol, where a high (low-glycemic) vegetable intake counteracts some of the negative impacts of the high fat intake. These are important questions to explore and studies that don’t consider these questions ultimately aren’t translatable into evidence for making decisions.

I was in ketosis for 8mths. I ate everything green… straight from my garden, Lots of eggs from my free range chickens, lots of coconut oil, animal fats, olive oils, meat, fish, nuts, dairy, occasional fat bombs like bacon grease coffee (yum). Always checking ketones, below 20 carbs/day (if that). Always in mild ketosis….lost all my love handles, looked ripped. Was exercising 5-6 days a week. Competing in endurance races….but…I think it was killing me. Inflammatory markers went through the roof. CRP 3, Lp-pla2=230, ldl-p almost 1800, total cholesterol went over 300, homocysteine=15. I have bruises on my butt and back that have never gone away. My teeth turned brown like an anorexic. I’m sure there’s a reason for all this but how the hell can one know what exact freaking food to eat to keep from dying on this type of diet. At the rate things were going for me, I was a heart attack waiting to happen. 5 mths after exiting ketosis my inflammatory markers dropped to near perfect levels with the exception of homocy.

“but how the hell can one know what exact freaking food to eat to keep from dying on this type of diet.”

Perhaps, just perhaps from the tons of *real* resources out there, like PubMed or the various real health sites. And I am very curious if you had those values checked before the diet? What you’re describing is the diet causing what it is used to *cure*.

NEquals1, if I were to guess based on your markers, you might’ve lacked adequate intake of green vegetables, or had a problem absorbing vitamin B, particularly folate. Also, I would question the source of animal fats you were consuming, as grass-fed vs. grain-fed animals have a drastically different fatty acid profile, grain-fed fat being highly pro-inflammatory. Instead of the bacon fat bombs, I would’ve opted for organic ghee or other healthier fat with very low PUFA to stay in ketosis. At a quick glance, you sure seemed to have followed the recommended keto protocols, but before getting discouraged, I’d question the source of the proteins and inflammatory fats you may have overloaded in your diet to end up lacking in other vital nutrients and minerals. I personally don’t think a strict keto diet is healthy in the long run (but useful for therapeutic resets) and opt for a modified keto/paleo while limiting (but not eliminating) inflammatory excess carb to upkeep thyroid and liver functions. Unless a person has a severe metabolic or clinical disease, conditioning the body to effectively metabolize various sources of fuels seems to be much more sensical in the long run.

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