Is ketosis safe? The truth is that we cant say for certain that it is 100% safe. Humans dont understand everything under the branch of nutritional science and probably wont for a very long time. As an individual, the only thing you can do is take a look at the research yourself and form your own conclusion.
Personally, through the reading Ive done and the experience Ive had with the Keto diet, Ive formed my own conclusion that ketosis is safe. Could I be wrong? Absolutely. But I could also be right. Im willing to take that risk in order to follow a diet which could maximize longevity, well being and function.
My personal conclusion shouldnt matter to you though. You need to do your own research and come to your own conclusion. Ive put together this post to organize all of the issues surrounding the safety of ketosis so that you can make your own decision.
In trying to prove something to be safe there are two ways to go about it.
This article will dispel the top 10 claims people make in an argument to label ketosis as dangerous.
Like I said, the science on ketosis is still quite immature. The following data is not meant to 100% prove or disprove the safety of ketosis. Its merely the information we have available today which can help us form a nutritional strategy we feel is best for ourselves.
Im not a doctor or a researcher. The following information is material Ive collected in my attempt to feel confident following a Keto diet indefinitely.
Most of it is sourced from doctors or authors although I have also included anecdotal accounts from experiences posted on message boards and Reddit. I know, much of the information here isnt sourced directly from science journals. To be honest, the hard research on ketosis is currently lacking.
The best information comes from reputable doctors and authors who have years of experience with the diet. In the end, you will have to take a slight leap of faith in placing your trust on the anecdotal experience of thousands of people who have experienced, benefited, and shared their knowledge of this diet.
Until hard research is funded and performed on the different aspects of ketosis I see no reason we cannot use the experience and results of others to assist us. Those alive today may all be dead before science proves the 100% safety of the Keto diet.
Im not waiting for that day.
Life is about risk and reward. This is one risk Im willing to take in order to reap the immense rewards of the Keto diet.
Reality: The brain DOES need glucose but not very much; About 30g-50g/day . The body can synthesize this glucose from dietary protein through a process called gluconeogenesis . Carbohydrate not required.
But what about the rest of the brains daily energy needs beyond this 30-50g glucose requirement?
Most people are aware that the brain is powered by glucose. Very few are aware that it can also run on ketones and that ketones may actually burn more efficiently with less waste.
Once the body has become fully Keto adapted the brain gets up to 75% of its energy needs from ketones. The remaining 25% is obtained from glucose which as mentioned can be synthesized from dietaryprotein.
The body can synthesize glucose from protein in a process called gluconeogenesis, therefore unlike protein and fat,a person can live without eating carbohydrates(3,6).
When I was taught about biochemical fuel-burning, I was taught that glucose was clean and ketones were smokey. That glucose was clearly the preferred fuel for our muscles for exercise and definitely the key fuel for the brain. Except heres the dirty little secret about glucose when you look at the amount of garbage leftover in the mitochondria, it is actually less efficient to make ATP from glucose than it is to make ATP from ketone bodies! A more efficient energy supply makes it easier to restore membranes in the brain to their normal states after a depolarizing electrical energy spike occurs, and means that energy is produced with fewer destructive free radicals leftover.
If youre on a very high fat, very low carb diet like a traditional Inuit diet your brain will eventually be able to use fat-derivedketonesfor about50-75% of its energy requirements. Most ketones are produced in the liver, but astrocytes in the brain alsogenerate ketones themselves for use by neurons. You think wed have that kind of set up in our brains if ketones werent useful to have around? If all we could do was burn glucose up there, what would be the point of even having localized ketone factories?
Mark SissonMarks Daily Apple
If someone tries to tell you that ketosis is dangerous because youre starving your brain of glucose you can either stop listening to them or you can educate them.
Heres the thing, the Keto diet can be executed in many different ways. The only requirement for achieving ketosis is to restrict carbs and limit protein so that the bodies glycogen reserves are depleted to the point that ketosis kicks in. If you do that by eating hot dogs and margarine then I agree with this claim, you are on a dangerous nutrient-deficient diet. However, if one chooses to achieve ketosis by eating fatty cuts of quality meat, dairy, nuts and plenty green leaves and fibrous vegetables-they are on a nutrient dense, complete diet.
What about the nutrients found in high carb grains, fruits and vegetables? What are we missing out on?
The fact is that compared to many vegetables, fruit is actually a pretty poor source of vitamins and minerals. And grains? Not only can the trace vitamins and minerals in grains be found more richly in meats, dairy and other keto friendly foodsthere is speculation that phytates and tannins found in grains can block absorption of some vitamins and minerals.
Schlemmer U1, Frlich W, Prieto RM, Grases F.PubMed
In practice most people who begin following a Keto diet actually end up eating many more servings of nutritional low carb fruits and vegetables than they previously were. Once you cut out all of the candy, chips and soda suddenly tomatoes, avocados, olives, spinach and broccoli start looking a lot more attractive.
Unlike proteins and fats, theres no such thing as an essential carbohydrate. Theres nothing a carbohydrate has to offer the body that couldnt otherwise be obtained from fats and proteins.
In practice, youll probably consume more vitamins and minerals on a ketogenic diet than you did on a standard American diet (SAD), as long as you are eating whole foods (i.e., natural fats, meats, leafy green vegetables) and not packaged low carb junk food.
Ellen DavisM.S.Applied Clinical NutritionKetogenic Diet Resource
Meat is the only nutritionally complete food. Animal foods (particularly when organ meats are included) contain all of the protein, fat, vitamins and minerals that humans need to function. They contain absolutely everything we need in just the right proportions. That makes sense, because for most of human history, these would have been the only foods available just about everywhere on the planet in all seasons.
Georgia Ede MDDiagnose Diet
This should put things into perspective: gram for gram, broccoli, kale and cauliflower all have more vitamin C than an orange. The high carb foods we famously believe to be the major sources of nutrients are often beat out by low carb meat, dairy or vegetable options.
Reality: It is physiologically impossible for anyone with normal pancreas function to develop Keto-acidosis.
The fact that Keto-Acidosis is used as an argument against the safety of ketosis is really a grand revealer of just how ignorant and lazy some pundits are in attacking the diet. I cant help but cringe when I think that the logic displayed here might be as lazy as well they both have keto as their root word, ketoacidosis must be the result of ketosis. Even more cringe worthy are the numerous cases of TRAINED MEDICAL DOCTORS advising against ketosis out of fear for ketoacidosis. Comon society, you can do better than that.
Unless you cannot produce any insulin from your pancreas (as is the case with type I diabetics, who do have to be much more careful with ketosis) you are at zero risk of keto-acidosis.
Heres how Keto-acidosis occurs(or doesnt) as explained by the venerable Peter Attia:
What is diabetic ketoacidosis? When a diabetic (usually a Type I diabetic, but sometimes this occurs in very late-stage, insulin-dependent, Type II diabetics) fails to receive enough insulin, they go into an effective state of starvation. While they may have all the glucose in the world in their bloodstream, without insulin, they cant get any into their cells. Hence, they are effectively going into starvation. The body does what it would do in anyone it starts to make ketones out of fat and proteins. Heres the problem: the diabetic patient in this case cant produce any insulin, so there is no feedback loop and they continue to produce more and more ketones without stopping. By the time ketone levels (specifically, beta-hydroxybutyrate) approach 15 to 25 mM, the resulting pH imbalance leads to profound metabolic derangement and the patient is critically ill.
But this state of metabolic derangement is not actually possible in a person who can produce insulin, even in small amounts. The reason is that a feedback loop prevents the ketone level from getting high enough to cause the change in pH that leads to the cascade of bad problems. A person who is said to be keto-adapted, or in a state of nutritional ketosis, generally has beta-hydroxybutyrate levels between about 0.5 and 3.0 mM. This is far less than the levels required to cause harm through acid-base abnormalities.
Keto-adaption is a state, achieved through significant reduction of carbohydrate intake (typically to less than 50 grams per day), where the body changes from relying on glycogen as its main source of energy to relying on fat. Specifically, the brain shifts from being primarily dependent on glucose, to being primarily dependent on beta-hydroxybutyrate. This has nothing to do with what a diabetic patient is experiencing in DKA, but does illustrate how poorly informed and quick to react the medical community is. DKA and nutritional ketosis (or keto-adaptation) have as much in common as a house fire and a fireplace.
Peter Attia M.D.Eating Academy
If you encounter anyone who uses the ketoacidosis argument against Keto you can throw their credibility out the window right there.
(btw, when I say something like throw their credibility out the window I dont mean to berate them during discussion. But you should know that once they use an argument like this, you are no longer in a debate. Calmly take the opportunity to explain the facts.)
Reality: Sort of truealthough I would argue the use of the word dangerous here. It is true that ketosis promotes water and electrolyte loss but this can easily be mitigated by ensuring adequate water consumption while making sure to consume foods rich in the key electrolytes: sodium, potassium and magnesium.
By switching to a ketogenic low-carb diet, you are essentially transitioning yourself from a water-retaining diet, to a water-flushing diet. There are a variety of reasons for this, including reduction of inflammation (water tends to be bound up in inflammation) and the depletion of glycogen stores (glycogen retains water) in your liver and muscles.
Because you are not eating a diet that causes you to retain water, youre going to find yourself urinating quite frequently (maybe even once per hour or more when you start!). As a consequence of this, youre going to lose electrolytes. Youll want to replenish them.
Often time people know when they are low on electrolytes because of various accompanying symptoms that may include a range of things including muscle cramps, low energy, headaches, difficulty concentrating, and more.
The affects felt due to this flushingaffectionately referred to ask the Keto flu are no more dangerous than mild everyday dehydration. The solution is the same, drink water!
Reality: Claims that diet has any affect on cholesterol levels is unfounded, obsolete and shows a lack of modern understanding. Peter Attia will confirm this below. Further, theres burgeoning research for the argument that total cholesterol levels have little correlation with cardiovascular disease.
The history and continued study of diet, cholesterol and cholesterols relationship with disease is truly fascinating. The whole thing plays out like a mystery novel that I just cant put down. If youre interested in this topic and have an afternoon to spare I strongly urge you to check out Peter Attias series of cholesterol posts on his blog.
Most of the information I have here on cholesterol will be borrowed from Peters blog as I have zero credential in the area and I believe its only fair that you get the most up to date and accurate knowledge on this topic.
Im going to attempt a laymans description of the cholesterol story Peter has unfolded on his blog. Hopefully I dont butcher it too badly.
Ok, so I might have butchered that. Sorry Dr Attia.
Anyways, the takeaway is that diet doesnt affect total cholesterol levels but it does affect triglyceride levels. The higher our triglyceride levels the greater our LDL particle count and the greater our risk of heart disease.
One of the biggest misconceptions out there (maybe second only to the idea that eating fat makes you fat) is that cholesterol is bad.This could not be further from the truth. Cholesterol is very good!
Peter Attia M.D.Eating Academy
Eating cholesterol has very little impact on the cholesterol levels in your body. This is a fact, not my opinion. Anyone who tells you different is, at best, ignorant of this topic. At worst, they are a deliberate charlatan. Years ago the Canadian Guidelines removed the limitation of dietary cholesterol. The rest of the world, especially the United States, needs to catch up.
Peter Attia M.D.Eating Academy
Blood levels of triglycerides are a major risk factor for heart disease and are directly correlated to the amount of simple carbohydrates in the diet (5,6).
For that reason, it seems intuitive that low-carb diets would lead to a reduction in triglycerides, while low-fat diets should increase them.
This is indeed the case. Low-carb diets drastically reduce triglycerides, while low-fat diets either dont improve them very much or literally make them worse (7,8).
Kris Gunnars BSc MedicineAuthority Nutrition
So the takeaway from all of this is that triglycerides seem to be the biggest culprit in increasing chance of heart disease. What affects does the Keto diet have on triglyceride numbers? Here are a couple of anecdotal experiences from members on /r/keto:
Two cases of massive triglyceride reduction with the Keto diet! I know its just two cases but I can confidently tell you that these these results are typical. The Keto diet (or any diet low in carbohydrate for that matter) is very effective at reducing your triglyceride numbers.
Reality: When followed correctly a Keto diet is actually very high in fiber.
Sure, if youre just gonna eat hot dogs, cheese and margarine then sure, bring on constipation and a host of other ill effects. Theres no diet in which you can eat poor, low quality food and expect perfect health.
Many Ketoers claim to consume much more vegetables and fiber than they did on a standard American diet. After the effects of sugar overload wear off, your taste buds become reborn. Suddenly tomatoes, peppers and cucumbers actually taste sweet. Vegetables become your source of carbohydrate satisfaction (to the tune of about 20-50g/day).
Lets also get one thing cleared up, theres a difference between not pooping and constipation. Constipation is obvious blockage and discomforttheres something there but it aint movin. Not pooping is well, not pooping. Theres nothing there to come out. When you produce less waste, you poop less oftenand on Keto, youre going to poop less often. The body is very efficient at extracting nutrients from meats and fatty foods. The result is less waste. So dont mistake fewer bowel movements with constipation.
If youre currently on Keto and having problems with constipation here are the top 3 reasons:
Reality: Theres no science which supports that a low carb diet causes muscle loss. In fact, it might actually be the opposite. As more and more people adopt a ketogenic lifestyle the amount of anecdotal evidence in favor of ketosis as a great body building diet is growing rapidly.
The basis of the muscle wasting argument stems from a misunderstanding of the brains glucose requirements. If ketones didnt exist the brain would require much more glucose than it does in the presence of ketones. During a low carb diet the brain would be forced to break down protein to obtain this glucose. It would do this through either dietary protein or in the absence of sufficient dietary protein, it would go after body muscle. Fortunately, once ketosis kicks in the brain is able to obtain 70-75% of its energy requirements from ketones. The remaining 25% is much more easily obtained from dietary protein and thus body muscle is spared.
If you want some real world evidence for the efficacy of ketosis as a body building diet, head over to Reddit and check out /r/ketogains. This community is full of people dedicated to building muscle on a Keto diet. They have nothing to sell you and no reason to lie about their results.
This general muscle wasting assertion often comes from trainers and dietitians who really have not studied the science on muscle preservation. They will tell you that the brain requires at least 100 grams of carb per day and if you dont get those carbs in the diet, your body will break down your muscles to get it. This is true when ones diet is high carb, and no ketone bodies are available as an alternative source of brain fuel.
But for a person who is adapted to a low carb, ketogenic diet,ketosisprovides fuel in the form of ketone bodies for the brain, and the requirement for glucose drops to only about40 grams per day. The body can easily make this amount from dietary protein and glycerol from the break down of fatty acids
But for a person who is adapted to a low carb, ketogenic diet,ketosisprovides fuel in the form of ketone bodies for the brain, and the requirement for glucose drops to only about40 grams per day. The body can easily make this amount from dietary protein and glycerol from the break down of fatty acids.
Ellen DavisM.S.Applied Clinical NutritionKetogenic Diet Resource
Reality: The source of this claim comes from the misunderstanding that the Keto diet is high in protein. In reality the Keto diet places a limit on protein in order to minimize the conversion of protein into sugar. Furthermore, the claim that high protein consumption can damage kidneys and form kidney stones may also be unfounded.
If someone tries to tell you that the Keto diet is dangerous because of high protein consumption you can pretty much stop them right there. The calling card of the keto diet is Low carb, moderate protein, high fat and the recommended protein dosage usually falls between 60-120g/protein per day depending on your weight and lean body mass. This is not a high protein diet. Anyone eating significantly more protein than they require is probably kicking themselves out of ketosis and is therefore not following a keto diet.
To further damage the strength of this claim, theres no evidence that high protein consumption is the CAUSE of kidney damage and stones. The only correlation is that in people who already have kidney issues and a history of kidney stones, protein seems to exacerbate the issue. [3,4]
Reality: Gallstones are actually the result of an inactive gallbladder. What increases gallbladder activity? Fat consumption!
When the gallbladder is active it will constantly be flushing out and replenishing its contents. If it is inactive the contents will sit idle and be prone to stone formation.
But what about the cases of people on Keto diets dealing with gall stones? They eat a lot of fat and so their gall bladder should be flushed clean often right?
Well what are many people on a Keto diet trying to do? Lose weight right? I would guess that prior to discovering the Keto diet many of these people were caught in the trap of low fat dieting. This lead to months or years of low fat intake and consequentially low gallbladder activity. The gallbladder wasnt needed to digest fat and so it sat idle and stones were more likely to form. Once they made the shift to a ketogenic lifestyle and their fat consumption increased upwards of 1000%, the gallbladder kicked into high gear. If the previous period of low fat dieting had caused stone formation they are going to have to deal with flushing those stones out now while on a high fat Keto diet.
In a study of 51 obese people using an extremely low fat low calorie diet(just one gram of fat a day!) the gallbladder was examined by ultrasound before the diet and after one and two months. After one month four of the 51 participants had developed new gallstones. After two months more than one in four (13 people) had new gallstones! This on an almost fat free diet. Three participants needed to have their gallbladder removed during the study.
A third studycompared an extremely low fat diet with a diet slightly higher in fat during 3 months. More than one in two (6 of 11 people) in the group eating extremely low fat developed new gallstones. Nobody in the group eating more fat did.
Conclusion:Do you want gallstones? Avoid fat.
Reality: Ahh the fabled and legendary Keto could kill you email from Mom. Those of us on Keto know that this email is pretty much a rite of passage. Its only natural that mom worries about you, its what moms do. But the fact is that there are zero reported deaths as a result of ketosis. ZERO.
Lets put that into perspective.
100,000 die each year from pharmaceutical drugs.
6 million each year from tobacco.
3.3 million each year from alcohol related deaths and an estimated 15-30 million each year from deaths related to excess sugar consumption such as diabetes, heart disease, and obesity related disease. 
Surely the people who argue for the dangers of ketosis can better spend their time on issues which are actually dangerous to society?
Although we love them to death, our Moms typically have zero authority on the subject. When Mom heard you were going on a ketosis diet the first thing she did was head to google hell bent on finding any information about the dangers of the diet. Sure enough, 10 pages into google she found what she was looking for Never mind the first 9 pages filled with information about the safety and merits of the diet.
Most of the information contained in those articles your Mom finds on google will inevitably be addressed by some of the issues addressed here. Next time your mother or any of your family or friends to try tell you that ketosis is dangerous, link them over here and well take care of them
Lets leave off on this quote from Dr Eric Kossoff who was part of a 15 year study involving the long term safety of ketosis:
Despite its temporary side effects, we have always suspected that the ketogenic diet is relatively safe long term, and we now have proof, says senior investigator Eric Kossoff, M.D., a pediatric neurologist and director of the ketogenic diet program at Hopkins Childrens. Our study should help put to rest some of the nagging doubts about the long-term safety of the ketogenic diet, he adds.
The evidence is based on a study of 101 patients ages 2 to 26 years treated with the ketogenic diet for a minimum of 16 months and for up to eight years at Hopkins Childrens between 1993 and 2008. At the time of the follow-up, patients were off the diet anywhere between eight months and 14 years.
Dr Eric KossoffMedical News Today
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