Achieving ketosis by engaging in a very low-carbohydrate, high-fat lifestyle is an effective means of losing weight, breaking insulin and leptin resistance, reversing type 2 diabetes and fatty liver, reducing blood pressure, reversing the inflammation of visceral fat, and may even cause partial or total remission of selected cancers.
So what’s the problem?
The problem comes when people remain ketotic for extended periods. We know with confidence that long-term ketosis poses substantial risk for health complications because thousands of children have followed ketogenic diets over the years as a means of suppressing intractable grand mal seizures unresponsive to drugs and procedures, seizures that can lead to irreversible brain damage if not stopped. A ketogenic diet reduces seizures by approximately 55-85%. Because seizures are a chronic problem, these kids maintain ketosis for months to years.
The health of these kids have been formally tracked. What happens to them beyond the reduction in seizures? A number of phenomena emerge:
- They have high likelihood of calcium oxalate and uric acid kidney stones–Likelihood is 10- to 100-fold greater than in kids not on the diet. Kidney stones are uncommon in childhood, yet these kids commonly have kidney stones. The risk in an adult on a prolonged ketogenic effort is therefore high, also. Kidney stones are not benign–they are painful and can occasionally result in kidney damage (increased creatinine, urinary tract infections, etc.)
- Growth is stunted–Most of these kids fail to grow normally and fall into the 10th percentile for growth or less. Adults on a ketogenic diet are no longer growing, of course, but the growth impairment observed in children suggests that there is something fundamentally wrong with prolonged ketosis sufficient to impair normal growth.
- There are occasional instances of cardiomyopathies (heart muscle diseases, heart failure) and sudden cardiac death–The immediate causes are unclear, though at least some cases are due to severe selenium deficiency. The picture is muddied by the fact that some kids are fed large quantities of corn oil as a means of maintaining ketosis. Nonetheless, it suggests further uncertainties with prolonged ketosis.
- Constipation is the rule–as virtual elimination of dietary carbohydrates also means virtual elimination of prebiotic fibers that nourish bowel flora. Over time, this leads to metabolic distortions including a drop in HDL cholesterol, rise in triglycerides, rise in small LDL particles that lead to heart disease, rise in insulin resistance and blood sugar, rise in blood pressure, even if these parameters initially improved on the diet. This is also due to dysbiosis and lack of prebiotic fibers. While this has not yet been tracked in children, in adults we can expect that these distortions in bowel flora will, over time, also lead to heightened inflammation (bowel and elsewhere), diverticular disease (.e.g., diverticulitis), and colorectal cancer. Yes: prolonged ketosis can add substantially to risk for colon cancer. Other peculiar gastrointestinal complications of prolonged ketosis have also been observed, such as protein-losing enteropathies.
While many of the problems that develop with prolonged ketosis may be addressed simply by minding intake of prebiotic fibers, not all are, such as selenium deficiency and stunted growth.
If you want to use a ketogenic diet as a health tool, it would be wise to do so for no more than a few weeks at a time, as nobody knows how long is too long. And, of course, the period of time during which ketosis is safe can vary from individual to individual. Breaking ketosis is as easy as upping protein intake or having a glass of wine or whole piece of fruit.
Like the stress response, ketosis is a natural, physiological adaptation designed for short-term responses. In other words, an acute stress response to some danger or threat that involves increased adrenaline and cortisol release, increased heart rate and blood pressure, and heightened alertness is normal and can even save your life. But, if the stress response becomes chronic, as it may with divorce, prolonged caretaking of an impaired child or demented adult, PTSD, financial struggles, etc., then the stress response can have terrible health implications that include increased risk for Alzheimer’s dementia, heart disease, dysbiosis, inflammation, diabetes, and cancer. The same applies to ketosis: Acutely, ketosis is a normal physiological adaptation that serves us during periods of carbohydrate or calorie deprivation. Chronically, however, peculiar things happen with consequences that range from constipation, to selenium deficiency and cardiomyopathies, to colon cancer.
Another one of my concerns long-term is that many people are being persuaded to remain on a ketogenic diet over a long period. In 3, 5, or 10 years, we are going to see a sharp rise in colon cancer cases. People in conventional dietary circles will then point fingers at all of us engaged in unconventional dietary advice and we will be lumped together and labeled as dangerous fads. The key is to be smarter and to view ketogenic dieting as the short-term tool/response it is, not as a solution to all health struggles.
Also, be aware that, while diet can be an extremely powerful tool to regain control over many aspects of health, diet by itself remains insufficient for full health. Just as filling up the gas tank of your car with quality gasoline helps your car run well, but other aspects of your car need attention over time (change the oil, tune-ups, new tires on occasion, etc.), so it goes with diet. We must also pay attention to vitamin D and iodine status, the potential for common endocrine disruptions such as thyroid dysfunction, efforts to cultivate bowel flora, and other issues. Focus on diet as a start, not as an end.
So be ketotic—but just don’t stay ketotic for too long. Like an acute stress response, use it to your advantage but don’t allow it to become a chronic impairment of health.
Transcript:
I’d like to share some concerns I have about all the people who are coming to me saying that they’ve been on ketogenic diets for extended periods. Now, let me be absolutely clear, there’s nothing wrong with being ketotic or being on a ketogenic diet — for limited periods of time, and let me tell you why.
First of all, think of being ketotic as like having a stress response. A stress response is a natural physiologic process, right? If something dangerous or life-threatening is about to happen to you, you want to have the increase in heart rate, blood pressure, alertness — for safety. A stress response is a good thing. It’s a protective mechanism.
But what if you had the stress response 24/7; for extended periods, months, or even years on end? That’s what happens, right, when people are stressed to high levels like grief, the death of someone close to you, financial ruin, divorce. When stress goes on chronically, bad things happen. It gives rise to heart disease, cancer, diabetes, other bad effects, dysbiosis that changes bowel flora. Chronic stress, the stress response acutely, is a good thing. It’s a normal protective physiologic response. Chronically, for prolonged periods, it’s a very destructive process.
Ketosis is the same way. For brief periods of times, up to weeks, it’s healthy. It’s wonderful. It helps accomplish such things as accelerate weight loss, accelerate reversal of Type II diabetes, drops haemoglobin A1c, faster reversal of insulin resistance. It helps reverse fatty liver (often to normal), reduces blood pressure, reduces triglycerides — lots of wonderful effects of being ketotic. Problem: being ketotic too long; being on a ketogenic diet too long leads to adverse effects.
Here’s an area where we have good confidence in knowing that prolonged chronic ketosis is bad for you. There are children, kids, who have intractable seizures, grand mal seizures, unresponsive to drugs or sometimes even surgery. They’re put on a ketogenic diet, so of course, very low-carb, very high fat, and they have about 80% reduction seizures. It’s very successful, but kids who remain on this, on a ketogenic diet for a year, two years, three years, start to show bizarre effects — they have at least a tenfold increase in kidney stones, both calcium oxalate kidney stones, and uric acid kidney stones. These are kids who aren’t supposed to get stones at all. So the risk in adults is likely substantially even higher.
Kids have stunted growth. They often fall into 10th percentile. They don’t grow normally. They’re all real short. You and I am not growing, so that’s not a concern, but the fact that kids fall off the growth curve and experience a stunted growth process suggests there’s something fundamentally wrong with the diet, and no one knows what that is exactly.
Then there are the metabolic distortions of dysbiosis. When you fail to take in prebiotic fibers, and don’t make other efforts to restore or maintain healthy bowel flora, weird stuff happens. We’ve seen this happen over and over again in people on ketogenic diets; Atkins, ultra low carb diets, etc. People who do this typically have by a year, two years, or so, sometimes longer: HDL cholesterol drops, triglycerides start to climb back up (even if they’d dropped substantially at the start), small LDL particles on lipoprotein analysis — increase. Postprandial (after meal) distortions develop. Insulin levels go higher. Insulin resistance gets worse. Fatty liver can come back. Blood pressure goes up. You start to get constipated. You develop diverticular disease, and diverticulitis — and down the road, colorectal cancer.
These are not small matters. These are big deals, and this is what happens when you follow a ketogenic diet chronically.
Some of this can be addressed simply by paying to dysbiosis and cultivating healthy bowel flora, with, for instance, a high potency multi-species probiotic, lactate fermented foods, and prebiotic fibers. But a lot of people on a ketogenic diet have not been told this. They have assumed or dismissed the importance of bowel flora, which is a very foolhardy, because you could end up in, who knows, three years, five years, ten years, with a nice case of colon cancer.
One of my fears is that when this starts to happen, when the hundreds of thousands or millions of people following these diets develop bad effects, such as colon cancer, and other metabolic distortions, and diverticular disease, conventional thinkers will say: “see we told you all those fad diets don’t work and they’re gonna be dangerous” they’re going to label more rational approaches, like our approach, the Undoctored or the Wheat Belly approach as just a fad, when it’s not.
We have already incorporated, we’ve accommodated to the reduction prebiotic fibers by adding back prebiotic fibers, and we don’t stay ketogenic for extended periods. Being ketotic, following a ketogenic diet, is fine, but just like a stress response, don’t do it too long. Nobody knows how long a time is too long, but I think it’s probably a matter of weeks and then you should go off. Becoming non-ketotic is as easy as having more protein — having maybe an extra few bites of steak, or fish, or chicken, or having a glass of wine. For many of us, that’s all it takes to break the ketotic process. We’re not talking about going back to cupcakes and candy. It just means not purposely maintaining around-the-clock 24/7 365 days-a-year-ketosis, because bad things will happen if you do that.
I’ve been doing Wheat Belly WOE for more than a few years but in the past 6 months, I’ve made a big effort to watch my carbs. I still believe that I am getting 10-15 per meal so I figured that is fine. What I have noticed, though, with my bike rides (10-15 miles 4 or 5 times a week) my legs feel exhausted the moment I start biking, as if I have kind of a lactic acid build-up. If I bike this regularly and expend this much energy, should I be looking to increase my carbs to get rid of this tired leg feeling when I start bike riding?
Andrea Hill wrote: «…my legs feel exhausted the moment I start biking, as if I have kind of a lactic acid build-up.»
I don’t recall seeing a report like that over what is now nearing a decade on the various sites associated with Dr. Davis. Presuming that that your muscle mass hasn’t declined, metabolics (HbA1c, FBG) are in program range, and other blood chemistry is within normal clinical limits…
The more usual scenario is that such a symptom doesn’t appear until glycogen depletion well into an endurance exercise (at which time, feeding in slow carbs might help).
So I’m thinking that other possibly medical explanations need to be ruled out.
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Regarding Jimmy Moore: He has published over the years about what he does on occasion, which has included planned cheat days where he said, as an example, that he ate 30 slices of pizza. That was years ago, but some years later, he said he consumed diet sodas in abundance. While I suppose he has stopped this, a couple years ago he blamed his more recent weight gain on stress. Hence, by his own words, there are dietary and psychological issues that overlay whatever kind of ketogenic diet he’s been following, or not following, as the case may be. Therefore, anyone who uses JM as an example against keto diets probably also can’t argue their way out of a paper bag.
A couple years ago I followed Dr. Georgia Eade. I was shocked to recently hear her advocate for an all meat low fiber diet. It may work for her, and she claims there are so many antinutrients in plants not in animals that make animal flesh preferred food, but I cannot buy her argument. For one thing, such a diet is not sustainable for the planet. She may need such a diet for her own needs, but it goes against so much else I’ve heard from people, especially friends who are now feeling much better eating fermented foods and good fiber.
I my own life, I have found I can’t go too low on the net carbs, unless I also exercise by walking most days, otherwise my blood glucose seems to rise. We need to “eat to the meter” and I of late have been also monitoring my blood pressure. The key thing is to find out what works best for you.
Hey Coco: As evidenced by his thoughtful and reserved comments to you, Bob Niland, (the “chronic commentator” in your comments) is an informed contributor to this space and sanctioned by Dr, Davis to provide context and insight to the many aspects of the Wheatbelly/Undoctored program. He is also gentleman enough not to respond directly to your unnecessary ad hominem attack on those contributions or his “need to get a life” or your assessment that he is an “overeducated troll”. Tsk tsk Coco, not nice, not necessary, and above all, not true. Perhaps the addition of some prebiotic fibers to your diet would reduce the bile in your system? Bob, (you overeducated troll), I appreciate your role and look forward to your continued comments here…and thank you for them.
Chrisvt wrote: « Bob, (you overeducated troll), I appreciate your role and look forward to your continued comments here…and thank you for them.»
Thanks. I might use this occasion the provide some context here.
I can’t make the link to my disclosure statement (my username above) any more obvious without throwing nearly every reply of mine into moderation (due to link counts). Even if I did make the signature line into a link, a lot of new visitors to the blog would never click it (for many often-understandable reasons). It’s pretty unusual for a blog to have someone (other than the owner) handling inquiries, so checking for disclaimers and disclosures is not something the average web consumer would be expected to do.
Keeping in mind that there is almost no control of username entered, commenters here tend to fall into several categories:
1. long-term followers, many lurkers, who eventually surface
2. people new to the WB/Undoctored program, looking for resources
3. people with no exposure to the programs, following a link from a search result or someone else’s web page (where they may have been given information that is inaccurate, and very likely incomplete), and arriving here with zero context
4. spammers, blatant trolls, link vandals
5. {poof}
I have to assume that unfamiliar posters are in category #3, and do what I can to give them some program background whilst addressing any issues or questions they raise. I just ignore any ad hom. AH is so prevalent on the web that many doing it don’t even know what it is. My comments are also intended to be of use to the whole audience, and to be future reference material — note that my responses often are just deep links to prior responses.
The WordPress engine catches a huge volume of stuff in category #4, but some slips through and has to be dealt with by a moderator. I haven’t had to deal with any in more than month now.
So far, I haven’t personally gotten involved with moderation other than #4. I have a pretty thick skin. But management does want to keep the blog focused, and moving forward on optimizing human healthspan. If something disappears, odds are another moderator considered it to be “inappropriate, or abusive”, including but not limited to: needlessly hostile, grossly off-topic, unacceptable personal attack, furthering some other site’s agenda, open libel, pointless rant, reacting to a misunderstanding of the proposal, etc.
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Timely. I mentioned that I was thinking about taking a keto break. I decided to go ahead and do it and I don’t feel like 2.5 years of keto caused any permanent ill effects. My labs have always been great, and I don’t really see the glucose-sparing as a problem, except as an indicator that if you’re going to decide to do chronic keto you have to fully commit if you want to avoid these episodes.
Glucose-sparing was reversed in a few days of eating over 100 net carbs, as recommended by Adam Nally MD for that purpose, and then I went back to Wheat Belly proper levels of carbs. My FBG is somewhat higher than it was when I was in deep ketosis, but it’s within Wheat Belly guidelines. Of course I was doing a Wheat Belly version of keto, wherein I ate a lot of plant foods and paid attention to prebiotic fiber. My personal experiment leads me to believe long-term keto is not harmful for adults as long as you address the individual issues that can potentially lead to problems.
One thing I have found is that it’s pretty close to impossible to completely kick myself out of ketosis for any lengthy period of time without eating grains, if I follow the 15 net carbs per meal guideline. Blood ketones reach the low end of nutritional ketosis, but I only see completely non-keto levels occasionally. Ironically it was a low carb (8 net) Kind bar that did it most recently, and that effect only lasted a few hours. So in the strictest sense of the word I guess I am still keto most of the time, but I see no reason to force myself to eat more starch and sugar to counteract my body’s natural response to a diet that is not unhealthy in any way. There is nothing I want to be eating that I’m not already.
On the issue of the keto kids not growing, I’m trying to think of the name of that doctor who thinks that in adults who are no longer growing, that same effect is what slows age-related degeneration. He’s famous and I can’t believe I’m forgetting his name.
You may be aware of this but I wanted to draw your attention to one of several 18Century painters who chose to paint the wheat harvest in the 1860’s. In particular Harvest Rest by George Cole shows the height of the wheat at that time.
Some examples can be found here:- http://www.allartclassic.com/pictures.php?p=1&p_number=921&forder=1&countsp=15.
In some other paintings the stooks are taller than the harvesters.
Freddy wrote: «You may be aware of this…»
The runt mutant goatgrass aspect of the problem has not been overlooked. Here’s one of several blog posts on it over the years:
Bad Things Come in Small Packages
re: «In particular Harvest Rest by George Cole…»
I seem to recall Dr. Davis using one or both of those Cole paintings in presentations, although not on either of the blogs. Painters often captured what turned out to be important historical details.
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“One thing I’m a bit unclear on is: for the average person not working a specific problem, exactly what is chronic keto supposed to do, that enlightened ancestral (like WB/Undoctored) does not.”
It could be partly a placebo effect, but many people claim (who have no diseases their targeting with keto) that it helps their brain function better (better focus, memory, learning ability). David Perlmutter has said that kids with learning disabilities function better academically on a KD from what he’s seen. For everybody else I guess it’s just easier to lose weight for them on a KD and they feel better emotionally and mentally.
I just mentioned insulin because from what I’m aware it’s an important growth factor. Bodybuilders use it. This could be even more important for kids (and that’s maybe why they should be eating more carbs). Any idea why Peter Attia isn’t eating a ketogenic diet anymore? And I agree about Jimmy. I think there’s something he has that makes it difficult for him to lose weight and keep it off that’s not related to diet. It’s dumb that people use him as a personal case, one person, as a reason to avoid a KD. The vegan community attacked him over this, basically saying if he just went “plant-based” that he would be a lot healthier, lose the weight, etc.
DLM wrote: «Any idea why Peter Attia isn’t eating a ketogenic diet anymore?»
You could search his back blog for clues. It may not be coincidental that his focus seemed to shift to healthspan about the same time (which is a different concept than lifespan). Implications for KD left as an exercise for the student.
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Kidney stones and stunted growth huh? Keto diet proponents may deny all the claims. I believe one doctor in favour of it has said that kidney stones may only develop if you cheat on the diet (eat carbs). Maybe the stunted growth is from lack of insulin and/or carbs.
“Be ketotic… but only sometime”
You should tell that to Jimmy Moore. Maybe he will lose weight. Haha
DLM wrote: «Keto diet proponents may deny all the claims.»
One thing I’m a bit unclear on is: for the average person not working a specific problem, exactly what is chronic keto supposed to do, that enlightened ancestral (like WB/Undoctored) does not.
Of course, we can’t really make an A-B comparison here, because there is no single official KD. With any diet, beyond the macros, there’s a long list of other things to consider including program advice for fat types, key micros/doses, gut flora and key markers to monitor.
re: «Maybe the stunted growth is from lack of insulin and/or carbs.»
Well, like Dr.D. says: not presently clear. There are people for whom chronic keto is compelling, so the more we learn about side effects, and the sooner, the better (and ditto for exogenous ketones). But for people without a compelling KD case: ponder it, partner. Peter Attia did KD for a few years, and backed off.
re: «…Jimmy Moore. Maybe he will lose weight.»
Jimmy’s case seems to be sufficiently idiosyncratic that without his active participation, I doubt there’d be any point in exploring it here. I wouldn’t rule out the possibility of some sort of KD-induced metabolic rebound, and if that’s the case, I trust he’s not aligned too closely with keto to allow himself to critically examine the whole situation.
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How about the Inuit, the Masai, Stefanson and his family & friends, Bear (Owsley Stanley), etc.?
And how does this fit in with hypotheses about those of our ancestors who presumably ate animal foods only?
Tom Welsh wrote: «How about the Inuit,…»
Apparently not a full-time keto culture, and have a genetic adaptation to their diet (and are getting clobbered by the junk being flown in the from the south, but you probably knew that bit).
re: «…the Masai…»
I’ve only done a cursory search on the Maasai, but it appears they weren’t chronic keto either, plus they made soup from Acacia nilotica root, which, in addition to any other root crops, would provide prebiotic fiber, and their general state of food and personal hygiene would provide ample probiotics. I wrote “weren’t”, because the Maasai have more recently taken up maize, which they are likely to regret.
re: «…Stefanson and his family & friends, Bear (Owsley Stanley), etc.?»
We need to look at long-term results over statistical populations. The KD and ZC experiments and anecdotes, to be sure, have cast a revealing light on carbs.
re: «And how does this fit in with hypotheses about those of our ancestors who presumably ate animal foods only?»
Ancestral reflection is an important part of the WB/Undoctored approach to nutrition. Anything for which there isn’t an ancestral case gets at least a raised eyebrow. I personally haven’t seen any evidence for chronic (longer than seasonal) keto human cultures. I’m willing to be mistaken.
It’s pretty clear that humans are adapted to periodic keto, and it’s easy to conjecture about that being highly useful during seasonal deprivations of carbs (or of food entirely).
It’s also pretty clear that we can cycle in and out of keto on perhaps a daily basis, which would also be useful in unpredictable results of daily foraging and hunting.
It’s further pretty clear that we snap out of keto whenever “net” carbs are available, and when they are available, hunter-gatherers do eat ’em.
For context (for the benefit of new readers), the WB/Undoctored dietary recommendation of 50 grams net carb per day is right at what is widely seen as the borderline between glycemic and ketotic diets. Anyone following it is apt to be in ketosis for part of each day, typically during the extended fasting time that sleeping represents.
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Thanks, Bob. I was surprised at Dr Davis’ warning, but I take his (and your) statements seriously.