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Troubleshooting the Keto Diet

iStock-1397848192Social media is replete with astounding before and after pictures of lives transformed by weight loss on ketogenic diets. Word is also getting out about the use of ketogenic diets for mental health and putting type 2 diabetes into remission. So when a patient adopts a keto diet and doesn’t get the results they want, it’s understandable that they feel frustrated and disappointed. So, how can you help when a patient reports that a keto diet “isn’t working?”

Define “Not Working” 

The first step is to get clear on what their goals are. The solution for getting things moving in the desired direction depends on what someone is trying to accomplish. While a very low carbohydrate intake is the foundation for success on keto, fine tuning things should be guided by the desired outcome. When the main goal is weight loss, for example, and stubborn excess pounds aren’t budging, the change that gets things unstuck may be different from the approach needed if someone is using a ketogenic diet for epilepsy or for a mental health concern.

Weight Loss 

For slow or stalled weight loss, it’s important to first assess whether the patient has realistic expectations. Do they have an accurate body image? Is their goal realistic for their age and stage of life? Are they already at a healthy weight and trying to decrease their weight even further? If so, they might need to resort to extreme measures, which may work in the short term but are not sustainable for the long term.

If you’ve determined that it’s reasonable for the patient to desire weight loss, first assess the carbohydrate intake. Sometimes getting stubborn pounds to move is as simple as reducing the carb intake further. As mentioned in an article about common mistakes on keto diets, products marketed as “keto” – keto cereal, ice cream, granola, etc. – are often much higher in carbs than people realize. Sugar alcohols, modified wheat starch, tapioca starch and other common ingredients in these products can have a bigger impact on blood sugar and insulin than people realize, and a bigger impact on insulin means a more difficult time with fat loss.

If the carb intake is truly very low, the next culprit to suspect is excessive fat intake. Keto is considered a high-fat diet – it’s often referred to as LCHF, for low-carb, high-fat – but that doesn’t mean fat intake can be unlimited, particularly when someone’s struggling with excess body fat. When fat loss is the goal, only some of the fat in “high-fat” should come from food; the rest should come from stored body fat, so there’s no need to drown everything in melted butter or a mountain of cheese.

If a patient is not overdoing carbs or fat yet excess weight is still stubborn, another factor to investigate is thyroid hormones. As discussed in a past article, the standard TSH test is not always sufficient for identifying hypothyroidism. It’s not unusual for a patient to have a normal TSH even when T3 – the most potent, bioactive thyroid hormone – is overtly low or low-normal and suboptimal for that individual. A patient may experience the cardiometabolic benefits of carbohydrate restriction (lower blood sugar and blood pressure, lower triglycerides, etc.) yet struggle with excess weight if their metabolic rate is hindered by low T3.

Blood Sugar 

It’s not just weight loss that can be stymied by a carbohydrate intake that’s just a bit too high. Not getting the carbs low enough can also be the reason for persistently high blood sugar on a keto diet. Keto is so effective for lowering blood sugar in people with type 2 diabetes that insulin injections sometimes need to be discontinued on the very first day someone adopts the diet. Not everyone experiences such powerful results so quickly, but blood sugar should improve relatively rapidly on keto. If it remains stubbornly elevated, investigate the carbohydrate intake. (And don’t neglect unsuspected sources of carbs, such as condiments, medications, and supplements.)

If the carb intake is confirmed to be low, look into other possibilities for elevated blood sugar, such as use of steroids or other medications known to raise blood sugar. (Weight-positive medications can also be a factor in difficult weight loss but keto is often still effective in that context.) Poor sleep affects insulin sensitivity and glucose tolerance, so ask about sleep habits and recommend evaluation for sleep apnea if warranted.

Mental Health 

Ketogenic diets for mental health is a new area of research but results are promising so far. More research is needed, but it’s possible that some people won’t experience the mood-stabilizing effects of carbohydrate restriction unless they maintain a certain threshold level of ketones. Getting the blood beta-hydroxybutyrate concentration to what could be considered a “therapeutic level” might require a stricter macro-based approach, such as the 3:1 or 4:1 ratios more common in epilepsy treatment (3 or 4 parts fat to 1 part carbohydrate and protein combined). This is different from a keto diet for weight loss, where protein intake can be more generous and adding a lot of extra fat may interfere with the desired results.

Ketogenic diets are not guaranteed to improve mental health, but it’s worth fine-tuning the diet to see if facilitating higher ketone levels does have a bigger impact. There may also be a role for MCT oil or exogenous ketones in this context, and of course any key nutrient deficiencies that could impact mental health should be addressed, such as magnesium and vitamins D and B12.

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