In this series so far we’ve had a look at the history of the ketogenic diet, how to achieve ketosis, some recipes ideas, the quality of the fats, and the macronutrient ratios (fat:protein:carbohydrate).
Here we will discuss:
- Fasting and muscle wasting
- Measuring ketosis
- Ketone esters
- The darker side of ketosis
- Cyclical ketosis and ‘safe starches’
Fasting: Ketosis Helps to Avoid Muscle Wasting
Intermittent fasting and ketosis go hand in hand. In a state of starvation, your body switches into ketosis, using stored fat as an energy source. This also triggers processes like autophagy, where your cells perform spring cleaning on themselves.1 However, there can be an intermediary phase during fasting when you’re not in ketosis and you’re feeling negative effects, such as low energy and mood. Before the switch into ketosis, your body is more likely to use the proteins from your muscles to make glucose for energy; that’s something you don’t want to happen. In order to prevent muscle wasting like this, ketosis should be achieved rapidly. This can be done using ketone esters (which we discuss later) and MCT oil.
Clearing Some Confusion: Ketoacidosis
Sometimes ketosis can be confused with ketoacidosis, a condition found in diabetics where levels of blood ketones rise to a dangerous level. This is because diabetics cannot produce insulin. This cannot happen in healthy people because properly function insulin systems keep levels of ketosis in check.
Measuring the level of the three ketone bodies gives you an indication of the levels of ketosis you’re in, and what (foods) affect your level of ketosis.
The three ketone bodies
- beta-hydroxybutyrate (B-OHB) – measured from the blood using a ketone blood meter. Most accurate, but involves taking blood from the finger. Expensive and a nuisance.
- Acetone – measured from the breath. Acetone is produced from the breakdown of acetoacetate in blood. You can measure this using the Ketonix.
- Acetoacetone – measured in the urine. Using urine pee sticks. Cheapest but the most unreliable/inaccurate.
Ketone Esters: Ketones in a ‘Pill’
Ketones are produced in your body (endogenously). They can also be ingested – from an outside source (exogenously). These exogenous ketones are called ketone esters. Unlike MCT oil, which is ketone-forming, ketone esters are ketone bodies, and raise your levels of ketosis immediately. These have been developed by various research groups in the hope of achieving ‘ketosis in a pill’. They are used for elite sports performance and for deep-diving navy seals who need the protection that ketosis provides from oxygen toxicity. Exogenous ketones are wonderful, but they come at a hefty price. In England they can cost between £90–500 for 300g. Wow. In America they are selling for $75 for 300g. Interested? Try KetoCaNa. It can also be found on Amazon UK, but (due to importing) is unaffordable.
Triglycerides and Cholesterol on the Ketogenic Diet
You get high triglycerides by eating too many poor quality or spoiled fats. High triglycerides make you fat, increase heart disease, heart attacks, and stroke. This is also seen with high fructose consumption, but that’s hardly a problem on a low-carb diet. Vegetable oils, animal fats, and nuts and seeds cause high levels of triglycerides when they’re heated up and processed, in addition to large amounts of free radicals.
If you’re eating a high fat diet then you’ll have higher levels of circulating cholesterol. This isn’t a problem in itself – cholesterol is a fundamental part of our cells and hormones. The problem comes when you have high levels of inflammation in your body (indicated by HS-CRP, if you’re getting blood tests). High inflammation in your body is more likely to oxidise the circulating cholesterol, causing elevated free radicals, which damage heart and connective tissue. Thus, you need to keep inflammation low while in ketosis, otherwise eating all those fats will come back to bite you. What causes high inflammation? High stress, too much exercise, not enough sleep, and exposure to toxins (including mould from damp; non-organic meats; inflammatory foods like grains, dairy, legumes, nightshades, and vegetable and seed oils) or pollutants.
Cholesterol also interacts with free-circulating glucose in your body. When these glucose molecules can bind to the cholesterol, the liver cannot process them, so they can remain in the bloodstream for extended periods of time. The longer cholesterol circulates in the blood, the more likely it is to get stuck to the inside of a vein or arterial (endothelial) wall. This ends up in plaque formation and atherosclerosis. So high-fat diet + dark chocolate or red wine every night, or weekly cheat days with lots of sugar is not a good thing.
“The deleterious effects of fat have only been measured in the presence of high carbohydrate. A high-fat diet in the presence of carbohydrate is different than a high-fat diet in the presence of low carbohydrate” – Richard Feinman, PhD.2
What Are the Takeaways Here?
- Monitor the quality of fat you’re eating. Avoid large amounts of roasted seeds, nuts, nut butters, heated oils, or meats cooked at high temperatures.
- Keep inflammation low. Control stress, don’t exercise too much, get plenty of sleep, supplement with EPA/DHA fish or krill oil.
- Time your carbs wisely (if you eat them at all – after you workout).
- Don’t overdo the sugar binges.
Cycling Ketosis and ‘Safe Starches’: A Review
There is open debate whether we need to include carbohydrates (starches) in our diet. Let’s review:
- We need, and can tolerate, small amounts of ‘safe starches’ in our diet.
- We can incorporate these into a ‘cyclical ketogenic diet’, and time carbs after workouts and in the evening.
- We need carbs for our thyroid hormones, sex hormones, and mucous production (lining of the gut, sinuses, etc).
- If you’re more active, you need to eat more carbs.
- Sleep quality and dreaming quality decreases without periodic (every 10 days) re-feeds with carbs (white rice, sweet potatoes).
- As we become more fat adapted, we can tolerate higher levels of carbs whilst staying in ketosis, especially if we’re highly active.
With ‘cyclical ketosis’, you cycle in and out of ketosis by eating carbohydrates every 7–10 days. When you eat a carbohydrate, it is turned into sugar in your body, which raises your blood insulin levels, taking you out of ketosis. The more fat adapted you are, the quicker you will get back into ketosis, and can do so after an overnight fast and a fatty breakfast. ‘Safe-starches’ refer to starches that are non-gluten, non-legume foods; essentially white rice, sweet potatoes, and white potatoes. They are called ‘safe’ because they’re minimally antigenic; they don’t annoy the immune system that much, causing less inflammation.
- Starch isn’t adding anything that our bodies can’t manufacture. We don’t need an external source of carbs as our bodies can manufacture glucose from protein (through gluconeogenesis) and triglycerides (creating glycogen using the glycerol backbone of triglycerides), and mobilise our stores of glycogen (stored glucose) from the liver.
- There is no established need for dietary carbohydrate.
- Humans didn’t evolve with access to carbs in the winter, and ate small amounts during the spring/summer (some fruits/tubers).
- The problems with thyroid and sex hormones are only seen when the ketogenic diet is accompanied by
- Not eating enough total calories (easy to do in ketosis due to fasting and suppressed appetite).
- Iodine deficiency (very widespread).
- Lower levels of sex hormones (testosterone) seen in some people on the ketogenic diet aren’t necessarily bad, rather, an indication that the sex-hormone receptors are more sensitive, and require less of the hormone to act (in a similar way that you become more insulin-sensitive on a ketogenic diet).
What can we take away from this? What is true for one person might not be for another. Monitor yourself and see what works. Start your ketogenic diet off with 4–6 weeks of totally no carbs. Then start experimenting and see how you feel.
Essentially we don’t know, and must make the decision for ourselves based upon the evidence in front of us, and observation of our own bodies.
What to look out for:
- Positive: weight-loss, sustained energy, clarity of mind (see Ketosis 1 for all the benefits)
- Negative: sore throat, dry eyes or sinuses, poor sleep quality (waking up often during the night – using sleep cycle alarm clock can help you track this).
Either way, we should we vigilant in looking after our bodies with the following:
- Supplement with iodine (and selenium) to protect your thyroid. Iodine is extremely important for our thyroid as it is required to make thyroid hormones (T1, T2, T3, T4). Iodine is found in very high levels in seafood and seaweed. Always take iodine with selenium, or eat Brazil nuts.
- Keep mineralised. You can crave more salt when giving up carbs and you can mistake that for craving sugar. Sprinkle sea salt into your water (your body also absorbs water with salt better). Take a magnesium supplement. Sodium (salt), magnesium, and potassium all work together in your body, so you need enough of each!
- Branched-chain amino acids (BCAA). A small amount of these will be converted into glucose in the liver. This is a great way to build and maintain muscles without eating carbs, especially helpful when exercising.
- Collagen after your workout. Take collagen within 15 minutes of a workout to prevent the stress hormone cortisol from getting too high and preventing muscle gains. Eating starches has this same effect after a workout, so collagen is the perfect replacement. It has the added benefit of increasing the flexibility of your skin and ligaments.
- Experiment if you’re very active. If you exercise a lot and you’re well fat-adapted, you’ll find that you can tolerate higher levels of carbohydrates, and stay in ketosis. Try with some sweet potatoes or white rice after you work out. If you’re really serious then try UCAN Superstarch for endurance.
- Reality calls. Sometimes we just cannot avoid eating carbs. Dinner at a friends, some wine on the weekend, or you really just want to eat that whole bar of 90% Lindt. Cycling out of ketosis not a problem, and you can get back in quite easily. If you time it well (after a workout) then it may even help you build muscle.
A Typical Day on the Ketogenic Diet
Morning: Ketogenic drink (fatty coffee/tea/chocolate). With breakfast, or without, for intermittent fasting. (Remember, eating just fats has the same physiological effects as fasting as it doesn’t activate protein and carbohydrate digestion; it has the added bonus of keeping you full up and the cognitive enhancement from the ketosis).
You can put collagen in the morning fatty drink; this is great to keep your levels up (for that mucin production, joints, skin) but it won’t count as an intermittent fast as it will activate protein digestion. You will get hungrier earlier in the day as a result.
Lunch: Ketogenic meal. Lots of veg, some protein, and covered in fats.
Dinner: Ketogenic meal. Lots of veg, some protein, and covered in fats.
Pre-bed (optional): ketogenic drink. This keeps levels of ketosis high through the night, ensuring better sleep quality by keeping energy and blood sugar constant (often you can have poor sleep quality from dips in blood sugar during the night).
We’ve taken a deep dive into ketosis: understanding its history, myriad benefits, practical tricks, and things to be careful of when maintaining a ketogenic diet. Doing the ketogenic diet doesn’t mean you can’t eat primally, and vice versa. In fact, they go hand in hand, and an understanding of ketosis merely provides an explanation for what is happening to your body when you’re eating a low-carb, high-fat primal diet. Better understanding means more awareness of your body and ultimately more control. As with every way of eating, the biggest variable is your body, and only you know that. So when questions arise (e.g. should I go totally keto vs. cyclical keto), the answer should come through self-experimentation.
- Ketosis – Advantaged or Misunderstood State? (Part I) – The Eating Academy | Peter Attia, M.D. (2012, November 26). Retrieved January 19, 2016, from http://eatingacademy.com/nutrition/ketosis-advantaged-or-misunderstood-state-part-i
- Ketosis – Advantaged or Misunderstood State? (Part II) – The Eating Academy | Peter Attia, M.D. (2013, January 1). Retrieved January 19, 2016, from http://eatingacademy.com/nutrition/ketosis-advantaged-or-misunderstood-state-part-ii
- Introduction to Superstarch – Part I – The Eating Academy | Peter Attia, M.D. (2012, October 31). Retrieved January 19, 2016, from http://eatingacademy.com/sports-and-nutrition/introduction-to-superstarch-part-i
- Introduction to Superstarch – Part II – The Eating Academy | Peter Attia, M.D. (2012, October 31). Retrieved January 19, 2016, from http://eatingacademy.com/sports-and-nutrition/introduction-to-superstarch-part-ii
- Ketones and Carbohydrates: Can they co-exist? – The Eating Academy | Peter Attia, M.D. (2013, August 26). Retrieved January 19, 2016, from http://eatingacademy.com/sports-and-nutrition/ketones-carbohydrates-can-co-exist
- My Experience with Exogenous Ketones – The Eating Academy | Peter Attia, M.D. (2014, August 24). Retrieved January 19, 2016, from http://eatingacademy.com/personal/experience-exogenous-ketones
- Masiero, E., Agatea, L., Mammucari, C., Blaauw, B., Loro, E., Komatsu, M., … Sandri, M. (2009). Autophagy is Required to Maintain Muscle Mass. Cell Metabolism, 10(6), 507–515.
- Gedgaudas, N. & Kharrazian, D. (2014). RETHINKING FATIGUE: What Your Adrenals Are Really Telling You And What You Can Do About It. Primal Body, Primal Mind Publishing.