Very-low-carb and ketogenic diets have come a long way since being considered “fads” that were only good for weight loss, or, more clinically, for drug-resistant epilepsy. There’s now striking evidence for using this dietary therapy for mental health, putting type 2 diabetes into remission, reversing non-alcoholic fatty liver disease, and much more. However, numerous myths and misconceptions about “keto” lead some to think that this approach is contraindicated for them (or for their patients), when this is untrue, and they can implement this way of eating to address their concerns. Here, let’s look at six issues that are often thought to be contraindications for keto but for which, in fact, keto can be safe and effective.
Chronic kidney disease
A common refrain when people think about someone with chronic kidney disease (CKD) following a keto diet is, “But what about all that protein?” The first thing to understand is that keto is, first and foremost, a very low-carbohydrate diet, not specifically a high-protein diet. What facilitates shifting the body from fueling primarily on glucose to fueling primarily on fat (and generating ketones) is a very low carbohydrate intake. The quantity of protein suitable for any one individual can be customized to meet their needs and preferences. But even if keto did call for a higher protein intake, an increasing body of research suggests that this is not automatically harmful, even in those with compromised kidney function. A previous article went into detail regarding the efficacy of ketogenic diets in individuals with CKD, including keto diets that are higher in protein than is typically recommended for those with CKD. Moreover, ketogenic diets have been shown to actually halt progression of kidney disease and even improve CKD from stage 3 to stage 2.
One word of caution when implementing a keto diet in individuals with CKD: those taking SGLT2 inhibitor drugs should be monitored for ketoacidosis. Keto diets, by themselves, do not cause acidosis, but combining this class of medication with a keto diet may increase risk – a risk that these medications also increase even in people not on ketogenic diets,
Type 1 diabetes
It’s unfortunate that “ketogenic diet” and “ketoacidosis” both have “keto” in their names. Safe, physiological ketosis is completely different from ketoacidosis, but confusing the two states leads many people with type 1 diabetes to stay far away from keto diets. The reality is, a keto diet can be a powerful tool for reducing insulin requirements and also reducing the volatility in blood sugar that many type 1 diabetics are all too familiar with. Research shows that restricting carbohydrate intake can lead to substantial improvements in blood sugar control and reduced risk for long-term complications – including “double diabetes,” wherein someone with type 1 diabetes develops signs and symptoms of type 2, owing to insulin resistance related to injecting supraphysiologic doses of insulin over a prolonged period of time.
Of course, individuals with type 1 diabetes seeking to implement a keto diet must have medical supervision and understand how to adjust their insulin doses safely. For more information on carbohydrate restriction for type 1 diabetes, see the position paper from the Society of Metabolic Health Practitioners (SMHP).
Cholecystectomy
Published research in this area is lacking, but anecdotally, clinicians who use low-carb and ketogenic diets report no major issues in patients who have had their gallbladder removed. As mentioned earlier, keto is not necessarily a high-protein diet, but it also not automatically a high-fat diet, either. What it really is, is a very low-carb diet. Just as with protein, fat intake can be tailored to the individual. While some may need to specifically aim for a high fat intake, others will do well just by minimizing carb intake without drowning their food in melted butter and cheese or putting oil in their coffee. In fact, overdoing fats and oils is a common culprit in slow or stalled weight loss on a keto diet in those for whom that’s a goal. Those with no gallbladder who do experience digestive distress on keto can fine-tune their food to see if that helps, or consider using digestive enzymes or ox bile, which may also help.
Eating disorders
Contrary to what many would think, ketogenic diets can be helpful for individuals with select eating disorders. Research is still emerging, but interesting case reports show that this way of eating can help restore weight and improve mental health and overall wellbeing in people with anorexia nervosa refractory to standard therapies. A case series was also published highlighting the experiences of three patients with obesity and comorbid binge eating and symptoms of food addiction. Patients reported significant reductions in binge eating episodes and food addiction symptoms including cravings and lack of control, validated by improvements in clinical measuring tools such as the Yale Food Addiction Scale or Yale-Brown Obsessive-Compulsive Scale modified for binge eating.
It may seem counterintuitive that a strategy that specifically calls for restricting food in some way could be beneficial for individuals struggling with issues related to food and eating behaviors, but there may be something uniquely therapeutic about the metabolic effects of carbohydrate restriction that is not replicated by reduction of dietary fat or total calories, and which may be effective for improving anorexia and binge eating.
Vegetarian or vegan lifestyle
Looking at keto recipes on social media, it would be easy to think that keto is nothing but steak, bacon, and more steak … with an occasional piece of salmon for good measure. But this simply isn’t the case. As mentioned earlier, what makes a diet ketogenic is a very low carbohydrate intake—not whether the fat and protein come from plants or animals. An article published recently in Frontiers in Nutrition details the case report of an Indian man who achieved long-term medication-free type 2 diabetes remission on a lacto-ovo low-carb diet. Beans and pulses may be a bit too high in carbs for a strict ketogenic diet, but eggs and dairy foods provide adequate protein and nutrients, and additional fat can be enjoyed from nuts and seeds, avocado, olive oil, and coconut. And since carbohydrate tolerance varies on an individual basis, some may be able to include beans and other plant-based protein sources, depending on their ability to control their blood sugar while doing so.
Sensitivity to dairy foods
It’s easy to think people who are sensitive to dairy can’t follow a keto diet. After all, apart from stacks of steak and bacon, what you often see on social media are rivers of melted cheese, whole sticks of butter, and luxurious heavy cream lavished over everything. But the truth is, dairy isn’t necessary on keto. Dairy foods don’t provide anything that can’t be obtained from other foods. Fat and protein can be found in a plethora of other foods, both animal and plant origin. And while milk, cheese, and other dairy foods typically come to mind when you think about sources of calcium, there’s no shortage of non-dairy calcium sources that are suitable for keto, such as leafy greens and canned fish (e.g., salmon, sardines) with the skin and bones.
There is no one particular food required to be successful on a keto diet. Ketosis is not a food; it’s a metabolic state. And this metabolic state is achieved primarily through restricting carbohydrate intake. Some individuals may need to reduce protein intake as well (owing to the effect of protein on insulin and ketogenesis), but regardless of the total amount of fat or protein that is optimal for any one individual, that fat and protein can be obtained from plant or animal foods, and with or without dairy.
Anyone with a medical condition or specific dietary restrictions should seek medical supervision and guidance from a nutrition or dietetics professional before starting a ketogenic diet. Certain medications—insulin, anti-hypertensives, and SGLT2-is, in particular, may need to be adjusted very quickly after starting keto, and in the case of insulin, sometimes as soon as the first day of reducing carbohydrate intake.