Nutritional Ketosis and Ketogenic Diet FAQ

Dr. Stephen Phinney and the Virta Team

All About Ketosis

What is nutritional ketosis?

Nutritional ketosis is a natural metabolic state in which your body is fueled mainly by fats and ketones, instead of carbohydrates (glucose).

How do I get into nutritional ketosis?

Nutritional ketosis happens when dietary carbohydrates are significantly reduced (<50 grams per day) and the body’s production of ketones increases to maintain a blood level at or above 0.5 mM.

How can I tell if I’m in nutritional ketosis?

Ketone production in the body is a very natural process that can be measured at home by a medical device such as the Precision Xtra meter or Keto-Mojo meter.

What are ketones?

When we say ketones, we are referring to the primary circulating fatty acid metabolites beta-hydroxybutyrate (βOHB) and acetoacetate (AcAc)

What is keto-adaptation?

When maintained for several consecutive weeks, nutritional ketosis fundamentally changes the way cells work.

What does it mean to be fat adapted?

This term is often used synonymously with keto-adaptation, and commonly used to describe low-carb adapted athletes.

Ketogenic Diets

What is a ketogenic diet?

A ketogenic diet that is restricted in carbs and moderate in protein results in increased production of ketones.

What can I eat on a ketogenic diet?

There are plenty of delicious high-fat, low-carb options available, and you can eat out or cook at home.

Why is sugar bad for you?

When you consume sugar or carbohydrates (which get absorbed as blood sugar), this triggers an insulin response by your body.

How many carbs can I eat on a ketogenic diet?

Carbohydrate tolerance varies among individuals.

Should I count net carbs or total carbs?

On Virta, we recommend counting total carbohydrates, with the most of your food coming from real, whole foods.

Is a ketogenic diet healthy for everyone, not just people with diabetes or weight issues?

We humans are a very diverse lot, and there is no known diet that is perfect for everyone.

What is ‘keto flu’ and how do I avoid it?

The ”flu-like” symptoms that some individuals experience when starting the ketogenic diet is due to the body’s response to carb restriction.

Should I take vitamins or supplements on a ketogenic diet?

It is well known that whole foods should be emphasized over dietary supplements because essential vitamins and minerals found in foods are usually better absorbed than those found in supplements.

How much sodium, potassium and magnesium should I have on a ketogenic diet?

In short, 3000-5000 mg of sodium and 2000-3000 mg of potassium on average are needed as part of a well-formulated ketogenic diet.

How much protein should I eat on a ketogenic diet?

Most healthy humans maintain lean body mass and function during a ketogenic diet providing between 1.5 and 1.75 grams of protein per kg of ‘reference body weight.’

What are the best artificial sweeteners and sugar substitutes for a ketogenic diet?

Xylitol is among the better choices because it is a dental protectant, and because it provides usable energy.

Can I be vegetarian and follow a ketogenic diet?

Absolutely! While 10-20% of your daily energy need should be coming from protein, you can meet this need by consuming high protein, vegetarian and keto friendly foods.

Can I be vegan and follow a ketogenic diet?

Achieving nutritional ketosis while being a vegan is possible but this style of eating will be restrictive and require a large amount of pre-planning.

Can I eat dairy on a ketogenic diet?

There is no need for people to avoid dairy products unless they have specific symptoms brought on by their consumption (e.g., lactose intolerance).

Can I eat gluten on a ketogenic diet?

A ketogenic diet is naturally very low in gluten, but if you do not have gluten intolerance or celiac disease, there is no need to avoid gluten.

Are vegetables necessary on a ketogenic diet?

In addition to getting fiber, there are many other reasons to consume vegetables.

Do I need fiber supplements on a ketogenic diet?

There are clear benefits from fiber consumption for bowel function and blood sugar control in people consuming a diet high in carbohydrates.

Can I have whey protein on a ketogenic diet?

Whey protein is a double-edged sword: it has a very high biological value score, but it also causes higher insulin secretion.

What can I eat at a Chinese restaurant on a ketogenic diet?

You can ask for steamed versions of some dishes and then add soy sauce, which fits within the guidelines of a well-formulated ketogenic diet.

Ketogenic Diets and Diabetes

Does a ketogenic diet reduce insulin resistance long-term?

Insulin resistance improves promptly for most people when they begin a ketogenic diet, and the effect appears to be attributable to the ketones.

Can I reverse diabetic neuropathy, nephropathy, or retinopathy with a ketogenic diet?

We have many anecdotes of reversal of neuropathy, retinopathy, and nephropathy in people with T2D following a well-formulated ketogenic diet.

Ketosis vs ketoacidosis: What is the difference?

In contrast to this normal physiology of ketosis, pathologic ketoacidosis manifests with serum ketone levels of 15-25 mM (three- to ten-fold higher than in nutritional ketosis).

Can a ketogenic diet reverse type 2 diabetes?

Insulin resistance is the hallmark of type 2 diabetes and manifests as carbohydrate intolerance.

Heart health and cholesterol

Is a ketogenic diet safe for your heart?

In the context of a well-formulated ketogenic diet (high fat, low carb, moderate protein), the intake of fat is not only safe, but imperative for long-term success.

What happens to your cholesterol on a ketogenic diet?

For most people, a ketogenic diet leads to improvements in cholesterol, but there are sometimes transient rises in cholesterol levels during weight loss.

What happens to LDL cholesterol on a ketogenic diet?

A ketogenic diet typically leads to a broad range of improvements in blood lipids as well as other cardiovascular risk factors such as blood pressure and inflammation.

What happens to triglyceride levels on a ketogenic diet?

Triglycerides are among one of the most predictable changes when one adapts to and maintains a well-formulated ketogenic diet.

Do statins decrease the production of ketones?

There are no known problems associated with combining statin use with a well-formulated ketogenic diet.

Safety on a Ketogenic Diet

Is a ketogenic diet safe?

Nutritional ketosis, achieved by following a well-formulated ketogenic diet is a safe and beneficial metabolic state for most people.

What is ketoacidosis?

This is a distinct pathologic state that happens when insulin levels are extremely low, such as in a person with type 1 diabetes who cannot produce insulin.

Is it safe to increase salt intake on a ketogenic diet?

In the setting of a well formulated ketogenic diet, a modest increase in salt intake is safe, and does not raise blood pressure (Hallberg 2018).

Is it safe to follow a ketogenic diet during pregnancy?

This is an excellent question for which there is no solid scientific answer.

Is it safe to do a ketogenic diet while breastfeeding?

While there are many anecdotes of women nursing while following a ketogenic diet, there are no published large prospective studies demonstrating safety and effectiveness of this practice.

Is it safe to follow a ketogenic diet if you have no gallbladder?

The gallbladder is a storage organ for bile, which (among other functions) helps with the digestion of dietary fat.

Can I follow a ketogenic diet if I have no thyroid?

In general terms, taking thyroid medication can fully replace what the thyroid gland normally does.

Can a ketogenic diet help with Lyme disease?

The topic of Lyme disease is very complex, involving both an infectious cause and often a prolonged inflammatory response after the infection is eradicated.

How does a ketogenic diet affect kidney stones?

Our clinical experience is that kidney stones are rare during a well-formulated ketogenic diet.

Does a ketogenic diet increase your risk of gout?

There is a short-term increased risk of gout flares when initially entering into nutritional ketosis due to the competitive inhibition of ketones on kidney excretion of uric acid.

Is fasting safe?

Any regimen involving fasting beyond 24-hours has not been proven effective in sustaining weight loss long term.

Weight loss on Ketogenic Diets

Does a ketogenic diet cause weight loss?

Being in nutritional ketosis will accelerate the rate at which the body burns fat, and this is a fundamental key to the short- and long-term benefits of a ketogenic diet.

Is dietary fat burned before stored fat on a ketogenic diet?

For regular dietary fats, once they are digested, they enter the circulation and participate in what is called ‘fatty acid turnover’.

How can I lose belly fat on a ketogenic diet?

Losing central fat (belly fat) is one of the many benefits of a well-formulated ketogenic diet.

Troubleshooting a Ketogenic Diet

What causes muscle cramps on a ketogenic diet?

Cramps may occur for a variety of reasons. A mineral imbalance may manifest in physical symptoms like cramps and is often resolved by magnesium supplementation.

What do I do if I get diarrhea on a ketogenic diet?

Diarrhea is not a common side effect of a well-formulated ketogenic diet. If it occurs, it likely due to well-intentioned but incorrect food choices.

How do I fix constipation on a ketogenic diet?

Many people assume that constipation while following a well-formulated ketogenic diet is due to inadequate fiber.

Does keto cause hair loss?

Hair loss is not commonly seen with a well-formulated ketogenic diet. Here are a few causes of hair loss.

What causes keto rash and how do you fix it?

In our experience, ‘keto rash’ is relatively rare. In the cases we’ve seen, it tends to occur early in the course of a ketogenic diet.

Why do ketone levels vary throughout the day?

Individuals vary in their blood ketone levels (i.e., beta-hydroxybutyrate – aka BOHB) over the course of a day and from day to day.

What are the consequences of cheating or lapsing on a ketogenic diet?

Intermittent breaks in adherence to ketogenic diets has not been studied carefully in humans.

How should I interpret and apply CGM data?

The use of continuous glucose monitors (CGM) serves a variety of purposes and depends on the individual.

Fats and Oils on a Ketogenic Diet

Which fats and oils should I eat on a ketogenic diet?

On a well-formulated ketogenic diet where 70-80% of your daily energy comes from fat, the majority of your dietary fat should be from sources of monounsaturates and saturates.

Can I eat canola oil on a ketogenic diet?

Sources of saturated and monounsaturated fats should provide the majority of your dietary fat intake.

What is the best ratio of MUFA, SFA and PUFA on a ketogenic diet?

In general, people don’t tolerate high amounts of polyunsaturated fats (PUFAs) as part of a high fat diet.

Can I use olive oil as a cooking oil?

Every oil or fat has a temperature range within which it performs best and a point at which it begins to breakdown (smoke point).

Is fat the most satiating macronutrient?

Satiety is very subjective, so it’s hard to measure it precisely.

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