Over the past few decades, the Ketogenic Diet has gone from a therapeutic, medically prescribed diet for a very specific portion of the population (children with epilepsy, and most notably, those who do not respond to drug therapy) to a popular weight loss diet. I am regularly coming into contact with folks who are are actively having a go at it, or know someone who has had tremendous success with it.

While this diet has the potential to significantly improve one's body composition, it's not one that I'd freely recommend to clients as a long term solution. In fact, before I carry on, I will remind you, the reader, that I am generally not supportive of 'diets' and that following a diet that has been simplified for mass consumption doesn't always result in you finding your best health. When it comes to weight loss (or the reasons for weight gain to begin with), we are all highly individual and there are often far more factors involved than simple macro nutrients.

That being said! This diet, when done with care, can be quite beneficial for some. I love the focus on high fats and the reduction of grains. I worry, however, about the lack of fibre, fruits & vegetables and the possible anxiety that can come with the rigidity of this diet.

So, before you delve in (or if you've already delved), here are 10 points to consider to ensure you'll thrive on the inside as well as on the outside:

1. What's Your Past (and present) Relationship With Food?

The point of this diet is to be in a relatively constant state of ketosis. This means that your body is using fat for fuel rather than glucose, producing ketone bodies as by-products. To reach a state of ketosis, you must either starve or severely restrict your carbohydrates while increasing your fat intake. This can take 2 to 7 days of very strict dieting to achieve. To stay in ketosis, you must continue this strict reduction of carbs and high fat intake indefinitely. A small slip (too much protein or hidden carbs) can knock you out of ketosis. This very fine balancing act can be tremendously triggering for folks who are sensitive. If you have a history of disordered eating (of any sort!) or if you are finding yourself feeling anxious and unable to relax and enjoy a meal (especially for special occasions), this diet might be a bit dangerous. Remember, there are many ways to improve your body composition without being "in ketosis".

2. Check the Quality of Your Fats

A quick google search for a simple keto recipe will bring up some pretty unsavoury meals (with WAY too much dairy and processed meats). While I love consuming high fat foods, it is very important to ensure that the sources of fat and protein are the best that you can manage.

Commercially farmed animals are often fed hormones to ensure that they grow to a desirable size quickly. They're also often given antibiotics and other medications, either to treat or prevent illness due to the poor quality of their food and general living conditions. Those hormones, antibiotics and pesticides found in their food are stored in fat cells and are consumed by us when we purchase low quality, poorly raised meats.
Omega 6 fatty acids are found in abundance in most diets. They're polyunsaturated fats and belong to the same family as the all mighty omega 3's. They can, however, lead to inflammation if consumed from the wrong source. Arachidonic Acid (AA) is an omega 6 fatty acid commonly found in animal fats, dairy, and eggs. AA can lead to increased inflammation, poor immune function and sodium retention by the kidneys. Conventionally produced meats are often higher in arachidonic acid and lower in omega 3's than those from pastured animals. Again, this is due to their poor corn and soy based diets. Get good omega 6 fats from hemp hearts, pumpkin seeds, flax oil and borage oil and ensure that you're getting a good amount of omega 3's from a good daily fish oil supplement and, of course, wild caught fish. Pastured, grass fed and naturally raised meats are generally higher in omega 3's.
MCT fats from coconut milk and coconut oil are excellent for absolutely everybody, and especially for those on a ketogenic diet. Medium chain triglycerides are sent straight to the liver via the hepatic portal vein and converted to ketone bodies for for immediate energy needs. Using coconut and MCT oil during a ketogenic diet is very helpful for extending a fast and for stimulating ketosis.
When it comes to affordability of good quality fats and proteins, ensure that the meat you purchase is at least hormone and antibiotic free. A great tip I recently saw is that if you can't afford pastured, organic, free range meat (few of us can!), consider purchasing more affordable low fat meats and adding your own quality fats to your meal (avocado, coconut oil, olive oil, lard, duck fat, etc).

3. Cut the Dairy!

As mentioned above, dairy is a source of arachidonic acid, which, when consumed in large quantities with other animal fats can create an imbalance in inflammatory pathways. Also, excessive dairy can raise blood sugar and knock you out of ketosis. For folks who've reached a plateau with weight loss or just not feeling great on this diet, consider eliminating dairy. If you don't wish to eliminate it all together, stick with high quality, aged cheeses and full fat yogurt & kefir.

coconut cream.JPG — Consider replacing cream and milk with coconut milk (or, better yet, coconut cream!) for a good hit of MCTs.

4. Increase Your Quality Fibre and Fermented Foods

A very low carbohydrate diet can have a significant impact on your gut. When we eat quality fruits and vegetables, we're getting a great balance of soluble and insoluble fibres, including prebiotic fibre, the incredibly important food for our gut bacteria. When our bacteria start mowing down on the sugars and fibre found in carbohydrates, they release important byproducts:

Short chain fatty acids, which come with great health benefits - they help to reduce inflammation, improve fat and carbohydrate metabolism, improve blood sugar control and act as the main fuel for the cells lining the colon.
Indolepropionic Acid - released as a by-product of certain fibre-loving bacteria, it's associated with increased insulin sensitivity and reduced inflammation.

As fermentation in the gut is reduced (because we're low-carbing -it), our gut PH increases, becoming more alkaline. The gut is generally more acidic at the top of the small intestine and more alkaline towards the colon. This supports the right types of bacteria in the right locations. A shift in PH can have a dramatic impact on the population of our gut bacteria, impacting digestion and nutrient absorption, immune function, weight management, mood and brain health and so much more. This shift also makes us more susceptible to pathogenic bacterial infections.

Just think about a jar of fermenting pickles. As fermentation gets underway, the PH inside of the jar decreases, making it more acidic. This acidic environment is what allows for a greater quantity and diversity of bacteria to grow within the jar, improving the flavour, texture and health benefits of those pickles. The PH inside of that jar is its main mechanism of preservation. Pathogenic bacteria that cause spoilage and food poisoning cannot grow under acidic conditions. The same goes for your gut. Here's a good read on the topic.

To ensure your microbiome stays in tip-top shape while you're doing keto, here are a few pointers:

Count net carbs: total carbs - fibre = net carbs. Some low carb dieters develop a fear of all carbs and wind up consuming very, very little fibre. I've even seen other advice-givers offer the suggestion to "avoid counting net carbs and stick with total carbs" as a tip for overcoming a plateau. I simply don't agree. It is not worth the long term damage to your digestive system to lose a few pounds quickly. We know SO MUCH MORE about the microbiome today than we did when the keto diet and subsequently the Atkins diet was popularized. We simply cannot neglect the importance of fibre in the diet.
Eat Fermented Veggies: Fermented pickles and sauerkraut are low in carbs and SO GOOD FOR YOU. They're a great source of fibre, many, many vitamins and minerals and, of course, probiotics.
Eat foods high in prebiotic fibre: Asparagus, garlic, onion, artichoke, leeks and dandelion greens are great low-carb options.
Take a prebiotic fibre supplement: There's a lot out there, so head over to a good health food store to pick one up. Acacia gum, guar gum and inulin are good examples. Some products I recommend are Regular Girl, by Lorna Vanderhaeghe, Gut Superfoods+ by Genuine Health and Clear Fibre by Renew Life.
Take a good probiotic: But don't take it alone. Do it with your prebiotic fibre. The health of your gut will help to ensure the lasting effect of your probiotics. Remember, it's that act of fermentation (feasting bacteria) in the gut that has the ultimate effect on your health.

5. Up Your Antioxidants

The restrictive nature of this diet can leave us nutrient-deprived and susceptible to oxidative stress. Oxidative stress occurs when our bodies are exposed to an overload of free radicals through excessive oxidation (the body's metabolism of oxygen for energy) and we don't have enough antioxidants to counter their effects. Many factors lead to excessive oxidation:

When the body uses glucose for energy (making a well-done keto diet a great prevention)
Stress, both physical and emotional
Inflammation from the diet (like grains, sugars, trans fats and high omega 6 intake)
Inflammation from the immune system when fighting an infection
Environmental and household pollutants

The effects of oxidation on the body are vast and far reaching, they include:

General immune dysfunction and increased infection
Skin, hair and nail degeneration
Cellular mutations
Cardiovascular dysfunction
Arthritis and joint inflammation
Neurodegenerative disorders

All of the above factors make it so important to ensure we're getting adequate antioxidants in the diet. If not possible through diet (and low carb or not, many of us find it challenging to get enough), a good greens supplement is my first go-to:

Spirulina - A great source of good omega 6 fats (including GLA) and omega 3's, spirulina contains many important B vitamins, electrolytes and other minerals, as well as a bit of protein. It contains the antioxidant phycocyanin, a powerful anti-inflammatory.
Morninga - I like to recommend this one over a synthetic multi-vitamin. It contains a wide array of vitamins and minerals (and in good quantities!) that are well recognized and absorbed by the body. It's also a decent source of protein and fibre. It contains quercetin, a well know antioxidant that can help to lower blood pressure, and chlorogenic acid, which is well known for its balancing effect on blood sugar (making it great for a keto diet!).
A good greens complex - There are a lot of high quality greens complexes out there that contain both of the above sources as well as many, many others, including cruciferous vegetables, a wider variety of sea vegetables, grasses and leaves (like wheatgrass, spinach and dandilion). Some good brands are Genuine Health (Greens Plus), Naka (Vital Greens) and Progressive (Vegegreens).

6. Electrolytes. Drink Up!

The "Keto Flu" is a common term that is associated with the electrolyte imbalance that occurs when we start a very low carb diet. A simple explanation for this is that when we stop taking in glucose through the diet, the body begins to convert our glycogen stores (the glucose stored in our muscles and liver) back to glucose for energy. With the release of those stores comes the water that was stored with them. As we shed that water, we shed electrolytes, causing a deficiency (this action is also the reason that we tend to lose an initial 10 or so pounds quite quickly on this diet, we're shedding water weight, not losing fat). Symptoms of Keto Flu can include:

Headaches
Moodiness
Insomnia
Muscle cramps
Fatigue & weakness
Nausea
Dizziness & lack of concentration
Dry skin & weak hair/hair loss (this one's associated with long term electrolyte deficiency and is a big complaint amongst keto dieters)

A common (and sound) recommendation is to consume electrolytes, either through diet or a good supplement, and that's a great idea. Start taking your electrolytes on day one of your diet. This will help to ease those symptoms. If you find that some, or all of the above symptoms are simply not going away, consider adjusting your diet to allow some carbs in. One important roll of insulin is to increase our cell's permeability to sodium and potassium. Chronically low levels of insulin can lead to an ongoing electrolyte imbalance, that simply cannot be replenished with supplementation.

Here are some steps you can take to ensure you're staying properly hydrated:

Start supplementing with electrolytes on day one. Some great choices are Vega's Hydrator, combined with MAGsmart by Lorna Vanderhaghe and Magnesium Synergy by AOR. Magnesium is great for cramps, muscle soreness, mood changes & anxiety and insomnia and both of the above suggestions contain at least some other electrolytes. EnerC is a vitamin C supplement with added electrolytes. All great additions to a keto diet.
Consider taking a potassium supplement on top of your electrolytes, as this one is directly affected by an insulin deficiency. Many nuts, mushrooms, avocados and dark, leafy greens are great food sources of potassium.
Salt your food!
Pay attention to your symptoms. Keto flu usually sets in after your body has used up its glycogen stores. This can take anywhere from 3 - 7 days. If your symptoms persist beyond about 2 weeks, consider upping your carbs.

7. The HPA Axis

When we start to hit our 30's and have kids and jobs and have to drive in the snow and get up early and when we forget to eat and fight with our partners and life just generally gets a bit more real, our body's ability to manage the stress we face becomes more difficult. Taking on a very strict diet will definitely add to the challenge. And this one can really mess with our hormones.

Full disclosure: I gave the Keto diet a go for about 4 weeks. I did lose about 10lb and I did get why folks often rave about this diet. I didn't feel hungry or deprived, I enjoyed the foods I was eating, my craving disappeared and I was able to finally overcome my night time snacking habits. I didn't, however, have any patience with my kids or my husband. I felt very moody, very uninterested in taking on extra projects or activities - no motivation at all. I felt like, emotionally, I was barely scraping by. This is the main reason that the Keto diet is not right for me. I simply cannot manage to feel unstressed on this diet. And you know what? There's a very good explanation.

The HPA Axis is a major neuroendocrine system involving the hypothalamus and the pituitary gland (both located in the brain) and the adrenal glands (located just above each kidney). These glands release very important hormones in a negative feedback loop in response to both physical stress (this includes exercise and nutritional stressors like inflammatory foods, food allergens, dietary deficiencies, electrolyte imbalance, starvation and very low carb diets) and emotional stress. It regulates digestion, blood sugar, electrolyte balance, the immune system, our mood & emotions, sex hormones & fertility, our sleep and wake cycle and metabolism.

The hypothalamus can communicate with other areas of the brain and other systems of the body. When we experience feelings of fear or anger, or when the immune system has been activated due to an infection or an excessive intake of inflammatory foods (those bad omega 6's!) or if our blood sugar dips too low, our HPA axis will become stimulated by way of the hypothalamus, and the stress response commences. As with most other bodily systems, chronic over-activation can, and often eventually does, result in malfunction. The above diagram shows just how many functions can go wrong when we are faced with too much stress. And Remember! Nutritional stress is probably the biggest hidden stressor that flies right under our radar.

Now, I am not suggesting that the Keto diet will for sure, without question over - stimulate the HPA axis and mess with your hormones (because, in reality, our typical western diet will do just that), but great care must be taken when we partake in an extreme diet like this one, especially if we're eating copious amounts of bacon, ham and cheese in the name of good health. Chronically low blood glucose, excessive amounts of protein and fats (particularly poor quality protein & inflammatory fats), nutritional deficiencies and dysbiosis in the gut can all trigger the HPA axis - chronically.

Here are some measures you can take to ensure that you do not, accidentally, put your body into an over-stressed state:

Do not consider the Ketogenic diet to be a lifestyle. This is a DIET, not a way of life. I recommend a gentle shift to a paleo style of eating after about 4 - 6 weeks.
Maintain your gut health and antioxidant status (see #4 & #5).
Address electrolyte status (see #6)
Take a good B complex and vitamin C. Both are important nutrients required by the adrenal glands that are easily depleted during stress.
Take adaptogenic herbs. I LOVE adaptogenic herbs and I like to recommend them for most folks, not just low-carbers. I've had great results with ashwagandha and rhodiola. Adaptogenic herbs help the body to physically adapt to stress, often lowering high cortisol levels. Ashwagandha helps the body to build and maintain muscle mass and rhodiola is energizing and helps the body to burn fat. Both excellent companions to a ketogenic diet.
Don't work out too hard. Stick with low impact, light exercises like yoga, walking, swimming and jogging. Attempting to start or maintain any kind of intense workout routine (especially using weights) WILL WITHOUT QUESTION push your body into a state of chronic stress, resulting in a cascade of hormonal dysfunction.

8. The Thyroid

HPA dysregulation directly effects the thyroid gland. The hypothalamus signals the pituitary gland to release thyroid stimulating hormone (TSH). TSH prompts the thyroid to produce very important hormones, T4 and subsequently T3. Emotional, physical and nutritional stress (extreme dieting) can halt the normal production of these hormones, leading to symptoms related to a low functioning thyroid.

Here's an example that is directly related to a very low carb diet:

The body naturally produces much more T4 than T3 (T3 being the active and slightly more important hormone of the two). T4 needs to be converted to T3 and is done so according to the body's need for it. When our glucose levels fall too low, the body assumes we've entered a state of starvation and starts to make metabolic changes to conserve all the glucose it can for the brain. One important job designated to T3 is to help transport glucose into to our cells. In this state of starvation (or very low glucose levels), the body starts to make excessive amounts of rT3 - Reverse T3. rT3 will not transport glucose into cells, it will, however, bind to thyroid receptors and block T3 from getting into cells. In chronically high amounts, rT3 can increase symptoms of hypothyroidism: increase weight gain, contribute to anxiety and depression, cause hair loss and lead to general fatigue. Not good! The worst part is, that once you've stopped dieting, the body doesn't just return to normal. You've given yourself a mountain of metabolic changes to climb to get back to a healthy state. This puts you at risk for gaining back more weight than you lost on the ketogenic diet.

Here are some things you ca do to maintain the health of your thyroid while in keto:

Take all measures listed in #7. Maintaining the health of your HPA axis is the absolute first step.
Include sea veggies into your diet. Iodine is a key nutrient involved in the conversion of T4 to T3. Sea kelp is an easy and very palatable one to start with if you're not accustomed to eating sea veggies. Bragg's Sea Kelp Delight is a lovely spice shake that you can add to salads and meats, etc. Dulse flakes are another great option that can easily be included (undetectably!) to smoothies and veggie dishes. Kimbu, wakami and arame are also great sources of iodine.
Watch those omega 6's! Again, those inflammatory omega 6 fats have been indicated in thyroid disorders. It isn't clear why, but it seems as though high intake of such fats are associated with a lower rate of T3 conversion.
Consider taking a thyroid complex. A good one should contain L-tyrosine, Zinc, selenium, copper and iodine. If you can find one with added ashwagandha, bonus! A good thyroid complex will help with the conversion of T4 to T3.
If you already have a thyroid condition, absolutely consult with a professional before partaking in a Ketogenic diet. You might be able to make a few adjustments to suit the needs of your body and still be able to thrive on a lower carb diet.

9. Should You Exercise?

You can, but keep it light.

The best exercises to partake in during a ketogenic diet are very low impact, light, relaxing exercises like walking, aquafit or light swimming and gentle yoga. While this diet allows for moderate protein intake, higher intensity workouts, especially those that involve weight bearing exercises, absolutely need carbs to adequately fuel the body and to carry that protein to the muscle. Carbohydrates are also important for avoiding excessive cortisol release during the work-out session (low blood sugar + exercise = cortisol release). Cortisol is released during exercise to convert glycogen (glucose stored in the muscle and liver) to glucose for immediate energy. This results in muscle wasting, poor exercise recovery, anxiety, extremely low blood sugar, frequent bouts of illness and general HPA axis OVER ACTIVATION. Too much of this and you'll end up with adrenal fatigue, a thyroid issue and a struggling immune system (at the very least).

Now..if you DO want to continue to work out at your usual intensity (or start a higher intensity workout plan) there are some things you can do:

Simply increase your carbs and reduce your fat intake. Your macro-nutrient ratios might look like this: 60% fat: 20% protein: 20% carbs. It's best to time your carbs around your workouts: 5% before; 5% during and 10% after, along with some protein.
Add a bit of MCT oil and branched chain amino acids to your workout shake. The body will use both as an immediate energy source when glycogen stores are absent.
Make sure that workout shake contains electrolytes too!
Take ashwagandha before your workout as it can have a wonderful effect on the adrenals and cortisol control. It also helps the body to build and maintain muscle.
Consume a prebiotic fibre supplement before bed, as this will help to replenish your gut bacteria (which can be damaged during stress & exercise) and will help to keep cortisol levels low throughout the night, improving sleep and muscle recovery (growth hormone is naturally higher at night, as long as cortisol is low and the quality of your sleep is good). I love Renew Life's Fibre Smart as it contains flaxseed and L-glutamine. L-Glutamine is excellent for reducing cortisol levels and improving the rate of recovery (it's also great for the stomach and digestion!).
You can follow a typical, strict keto regimen on your off days, however, focus heavily on increasing your fibre, antioxidants and HPA status, as this will help the body to recover from exercise.

10. Get a Good Book

Don't attempt this diet by simply following recipes that you find on the internet. It's very important to do your homework before you start. My favourite book is, by far, a wonderful, fun and very thorough guide written by Leanne Vogel, called The Keto Diet. In her book, she addresses many of the above concerns and creates individualized streams of the diet, including keto-friendly ways to increase your carbs if your lifestyle calls for it.

To Summarize

The Ketogenic Diet is an extreme diet that can come with short or long term side effects if not done with care. While many pro-keto advocates sing the praises of ketones and their 'clean fuel', not every body will be able to thrive on this diet. If you do want to give it a go, remember these points:

Focus on the quality of your fats and proteins and include quality fish and fish oil.
Include plant-based fats such as avocados (and avocado oil), hemp hearts, coconut oil & milk, nuts and nut butters.
Start supplementing with electrolytes ASAP.
Count net carbs, not total carbs. Get some fibre in your diet, take a probiotic, a prebiotic and eat fermented foods.
Take adaptogenic herbs as well as a good antioxidant greens formula.
Include sea veggies in your diet, they're a great source of iodine.
Focus on gentle, stress-relieving exercises.
Increase your carbs if you wish to work-out at a higher intensity.
Do your homework! Do not jump in head first and DO NOT do this diet to lose weight quickly for an event or vacation. This attitude will, without question, lead to post-diet weight gain and will increase your risk for hormonal imbalance. Take your current body on that cruise or vacation. This diet is for serious folks only.
Focus inward. Pay attention to how you're feeling emotionally and mentally while trying out this diet. If anxiety surrounding certain foods or numbers on the scale starts to set in, consider talking with someone and adjusting the diet to suit your individual needs. Sometimes we don't realize how triggering certain circumstances can be until they are actually happening (I'm currently raising my hand).