 Unless you follow a ketogenic diet, chances are your diet is high in carbohydrates. Most of these carbohydrates consist of starches, which are composed of long glucose chains. While regular starch is quickly digested and absorbed into the body, resistant starch is not as readily absorbed.1 In other words, it resists digestion. Hence, the term “resistant starch.” Resistant starches often function like prebiotics or soluble fiber. Foods composed of resistant starches move undigested through the stomach and small intestine to the colon, where gut bacteria can feed on them and convert a portion of them into beneficial short-chain fatty acids, such as butyrate.2-4 What’s so super about slow-release carbohydrates? Digestion benefits aren’t the only reason to take a closer look at resistant starches. Resistant starches have been shown to have numerous health benefits. For example, similar to soluble fiber, resistant starch consumption can have a “second-meal” effect by increasing the feeling of satiety, thus potentially helping people eat fewer calories.5-7 Adding foods high in resistant starches may also lead to improved insulin sensitivity.8 Some research suggests it may improve postprandial blood sugar levels9,10 A recent study compared the effects on blood sugar levels, over 90 minutes, with a proprietary resistant starch, known as UCAN SuperStarch® versus an oral glucose drink. The data indicated the oral glucose showed the typical “sugar spike” followed by a drop in blood glucose levels. On the other hand, the UCAN SuperStarch® provided a sustained glucose response without the sharp spike or crash in blood sugar.11  Resistant starch sources
Looking to ingest more resistant starch? It’s easy to get ample amounts of resistant starch through dietary intake. Foods high in resistant starch include potatoes (except sweet potatoes), green bananas, legumes, cashews, and some grains, including whole grains, oats, and rice.12,13 Note that some people find a diet high in resistant starch may cause stomach discomfort. Cook and cool! After cooking rice and potatoes (although not sweet potatoes), simply wait to eat these items until they have cooled completely. Cooling is important, as it converts some of the starch into resistant starch, allowing it to pass unchanged through the intestinal tract and providing fuel for the “friendly” bacteria in the colon. As always, make sure to discuss any dietary changes with your healthcare practitioner first! References:
Submitted by the Metagenics Marketing Team
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 “I’m addicted to sugar.” We’ve all heard or thought this before. Considering the American palate for highly processed, overly sweetened foods and the ubiquitous nature of sugar in advertising, we see evidence of a concerning shift. Sugar’s role in the American diet has moved beyond a character actor and into a starring role. Further, as discussed in the previous post, Sugar. How Much Is Too Much?, we consume far more sugar than is recommended for our health. But the question remains—are we addicted? More please: How sugar affects the brain While an ICD-10 code for “sugar addiction,” has yet to be established, an increasing body of research tells us that sugar has addictive effects on the brain.1,2 Like sex and drugs, consuming sugar stimulates the release of dopamine, a neurotransmitter that gives us a sense of euphoria and controls the reward and pleasure centers in the brain. But what may have evolved as a survival mechanism has gone rogue. The caveman sweet tooth From an anthropological perspective, we are hard-wired for sweetness. The pleasing taste of sweet foods was a conditioned reward, one which could increase early man’s survival odds. In times of food scarcity, a preference for more nutritionally dense foods might have provided the energy required to continue the hunt, outrun a predator, or simply avoid starvation. Flash forward a few hundred thousand years, and sugar is exponentially more abundant. Consistent intake of concentrated sugar can lead to changes in the brain’s dopamine receptors. Similar to increased drug or alcohol tolerance, over time, more sugar is needed for the same “high.” Cookies and cocaine So, the more you eat, the more you want. But, as for being “addictive” per se, animal studies have shown sugar consumption to have drug-like effects. These include sugar-related bingeing, craving, tolerance, and withdrawal. In fact, according to a Connecticut College study, Oreo cookies cause more neural activation in the brains of rats than cocaine.3 Taking control For many individuals, the only way to stop over consuming sugar is to stop the cravings. But the only way to end the cravings is to stop feeding them with sugar. So, in addition to cutting out the obvious forms of sugar—candy, baked goods, etc.—it is important to be aware of the less obvious forms of sugar in your diet. Over the course of a day, small quantities can add up, keep your cravings alive, and thwart your efforts to take control of sugar. So become a sugar sleuth. Here are five tips to get you started. 5 Tips for Identifying Added Sugars1. Beware of marketing geared toward dieters
2. Read ingredient labels, especially the first three ingredients
3. Beware of alternate forms and names for sugar
The journey to a healthy relationship with sugar starts with awareness. Watch for the next post in this series, which will feature strategies for taking control of sugar. References
 It’s not all fun and games when you’re living the low-carb lifestyle—but sometimes, it can be! Read on for a list of low-carb cocktails you can enjoy while following a ketogenic diet plan. First, here’s a simple rule of thumb: when consumed in moderation, any hard liquor can be considered acceptable by keto standards—either by itself or with plain, sugar-free sparkling water. Many sparkling waters contain zero everything, including calories, sugar, sodium, and, of course, carbs; just make sure you check the label or ask the bartender. For extra flavor, fresh lemon or lime juice is always acceptable. Whether you’re at home or at happy hour, these seven “ketolicious” cocktails won’t disappoint.  Vodka Soda: A simple, low-carb favorite.
What you’ll need:
Some like it sweet You don’t have to sacrifice sweetness in your low-carb cocktail fix. Each serving of this ketogenic simple syrup contains just 2 net carbs. What you’ll need:
Remember: If you choose to indulge in alcohol, it should always be in moderation. Enjoy responsibly. With all the keto-friendly cocktail options out there, you have yet another reason never to feel like you’re missing out on anything. Cheers!  The ketogenic diet has helped countless people who have struggled with managing their weight. But it is a diet that has now been split into two different diets: one diet’s been around for over 100 years; the other is a new spin for modern eating habits: How do you decide whether eating clean versus dirty keto is the right diet for you? Compared to the Standard American Diet (SAD), clean keto is not only used to help people lose weight, recent studies have also demonstrated it hosts a variety of health benefits that don’t include weight loss: Clean keto can help increase energy levels, promote brain function, and support athletic performance—for both professionals and amateurs alike.1 Those who have experienced the benefits of clean keto are understandably curious about the latest version of the diet, known as “dirty keto,” and how it holds up against eating clean. Let’s take a closer look.
Keeping it clean. The clean keto diet is based on the idea that eating a fixed macronutrient breakdown of mostly healthy fats, high-quality protein in moderation, and restricted carbohydrates (less than 50 grams per day) provides your body with the fuel you need to lose body fat without hunger, weakness, and fatigue.2 The reduction in carb intake puts your body into a metabolic state called “nutritional ketosis.”3 During this nutritional ketosis, your body no longer relies on glucose as a primary energy source. Instead, your liver converts fat into ketones–which are a great source of fuel for both your body and brain. Ketones also increase the brain-derived neurotrophic factor (BDNF), which works to support your brain’s existing neurons while encouraging new neuron and synapse growth.4 On the clean keto diet, you get most of your calories from healthy fats found in foods like avocados, grass-fed butter, olives, olive oil, coconut oil, nuts, and seeds. However, keep in mind that some nuts and seeds are better than others. You’ll want to choose those that are high in fats and lower in carbs; brazil nuts, almonds, walnuts, chia seeds and flaxseed are all good options. You can also eat all of the nonstarchy, leafy vegetables you want, as well as other low-carb vegetables like broccoli, peppers, cauliflower, green beans, asparagus, cucumber, and zucchini. In moderation, eat protein in the form of grass-fed meats, pasture-raised poultry, cage-free eggs, and wild-caught fish. Finally, if you want to reach for something sweet, 90% dark chocolate is your best option. On the list of what not to eat? For starters, remember that the clean keto diet restricts the intake of carbohydrates to achieve a shift from glucose to ketones as a primary fuel source. In order to avoid food high in carbs, limit fruit consumption—as it’s higher in sugar content–and forego fruit juice altogether. You should also avoid grains or starches such as rice or pasta, beans or legumes, root vegetables, and any low-fat or diet products, as they are typically highly processed and high in carbs. Let’s talk dirty (keto)Dirty keto follows the same macronutrient breakdown of fats, protein, and carbs as clean keto, with one major difference: It doesn’t matter which foods those macros come from. That is to say, on the dirty keto diet, instead of choosing good fats, like wild-caught salmon, grass-fed butter, and avocado, you eat a fast-food burger (without the bun), processed cheese, and pork rinds. Can you lose weight by following the dirty keto diet? Possibly. But the benefits halt there—and there are remarkable health drawbacks from the dirty keto diet that you should be aware of, too. For starters, this keto diet is missing vital micronutrients like vitamins, minerals, and enzymes that are necessary to your overall health. Furthermore, processed foods are usually high in sodium, which can lead to bloating and inflammation. You’re also more likely to regain the weight you lost and experience more cravings and less satiety. Dirty keto foods can trigger these cravings, bloating, and feelings of withdrawal which are symptoms commonly associated with what is known as the “keto flu.” You are what you feed your brainIn a healthy digestive system, the cells that form the paper-thin lining of the small and large intestines are packed very closely together. In fact, they’re so close that under normal, healthy conditions, only digested food (solutes) and water—can and should—enter the bloodstream. But when there is intestinal inflammation or inappropriate dietary intake, the tight junctions of the gut lining can easily be disrupted and become too porous. Diets high in chemical-laden processed foods—such as those often consumed on the dirty keto diet—can damage the gut lining and force it to become more permeable. These same factors also affect the balance of both the trillions of beneficial and harmful bacteria in the gut. When this balance is disturbed, harmful bacteria can get the upper hand and cause an increase in gut permeability. The result is intestinal hyperpermeability, or “leaky gut.” This condition can allow toxins, bacteria, undigested food particles, and other undesirable gut contents to enter the bloodstream and circulate to the rest of the body, including your brain. Not only does your gut affect your mental state in how you feel physically, but the reverse is also true: Your mental state affects your gut and gut health. This makes following the clean keto diet a better choice for your brain’s health. While dirty keto follows the same macronutrient breakdown as clean keto, there are marked differences in the two diets and their respective impacts on the body (and brain). A dirty keto meal can be a placeholder while you’re in a pinch, but it shouldn’t be part of an ongoing healthy eating regimen. Instead, by following a clean keto diet, you’ll not only find success losing weight and gaining energy, but you’ll also provide your brain with longer-lasting, healthier fuel. References:
 Consider these general diet descriptions:
So is a vegetarian or vegan ketogenic diet possible? Short answer: yes. The ketogenic diet differs from other diets in that it is not based around food groups you can or cannot eat; rather it is based on the macronutrient ratio your body requires to enter a state of nutritional ketosis (defined by an elevation of blood beta-hydroxybutyrate, the body’s primary ketone body). Thus, any style of eating can potentially be ketogenic, whether that is vegan, paleo, low FODMAP, etc. When you are approaching the ketogenic diet from a plant-based perspective, look at what plant foods comply to the macronutrient ratios you are following and stick to those. General guidelines for following a ketogenic diet:
Vegan ketogenic “food groups”:
Vegan food swaps
Tips & tricks
Submitted by the Metagenics Marketing Team  Wouldn’t it be nice to live in a world where the answers to all our health questions were black and white, (“Eat this, and you will feel good; don’t eat this, or you will not feel good”)? Unfortunately, health is not black and white, and often we have to navigate through the grey areas to find the truth. MYTH #1: A ketogenic diet increases your risk for cardiovascular diseaseThis myth is centred around the misinformation that saturated fat and cholesterol are the main causes of heart disease. Despite being shown that dietary cholesterol does not raise blood cholesterol1 and saturated fat has little correlation to heart disease,2 there is still a stigma around both. Cardiovascular risk does not boil down to a single biomarker, but rather encompasses a host of factors such as age, sex, total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, smoking, blood pressure, glycemic control, and more. Several of these risk factors may be mitigated by lifestyle changes. Low-density lipoprotein (LDL) cholesterol, as opposed to high-density lipoprotein (HDL) cholesterol, often gets a bad rap because the general understanding about cholesterol is that LDL cholesterol is the “bad” cholesterol, and HDL cholesterol is the “good” cholesterol. While this isn’t entirely misleading, what is misleading is referring to these as absolutes. LDL is usually misrepresented as the single factor that determines one’s risk for cardiovascular disease (CVD), when in fact there is more to the LDL and CVD risk story much of which is still uncovered. The danger lies with the small, dense LDL particles (as opposed to large, buoyant LDL particles),3 which have been shown to be associated with CVD.4 It is not uncommon to see a rise in total LDL levels when following a ketogenic diet. Recently published results of a one-year study of patients on a well-formulated ketogenic diet showed that the ketogenic diet did not change total LDL particle numbers but rather caused a shift toward an increase in large, buoyant LDL particles and decrease in small, dense LDL particles,5 which is a good thing! With all of this said, there is still a lot that is not fully understood about LDL cholesterol in the context of a ketogenic diet. As previously stated, LDL is not the only biomarker to consider when determining risk for CVD. Working with a keto-savvy physician is recommended when considering a ketogenic diet. When part of a weight management program including exercise and lifestyle modifications, the ketogenic diet can actually improve other biomarkers of CVD risk, such as weight,6 HDL cholesterol,6 blood pressure,5 blood levels of saturated fat,7 HbA1c,5 inflammation,8 and more! In fact, research has shown that carbohydrate-rich diets pose more of a health risk than ketogenic diets. High-carbohydrate diets have been associated with increases in small, dense LDL particles and reductions in HDL cholesterol along with raised triacylglycerol levels, all of which contribute to increased CVD risk.9 MYTH #2: The human body requires carbohydrates to survive This one may be hard to wrap your head around considering there are actually some cell types that do have an absolute requirement for glucose and cannot use fats or ketones for fuel, such as red blood cells which lack mitochondria, the organelle required for ketone utilization. Dr. George Cahill, former professor at Harvard Medical School, studied human body fuel metabolism under prolonged starvation, pioneering the understanding of ketones as an alternative fuel source to glucose. His research demonstrated that even after 40 days of fasting, glucose levels in the participants were maintained, despite consuming no food (Figure 1).10 So where does the glucose come from to fuel these cells when carbohydrates are restricted, such as with a ketogenic diet? Once you are keto-adapted (i.e. in a state of sustained nutritional ketosis), there are two primary sources that contribute to glucose maintenance. The first is from amino acids via a process called gluconeogenesis, where certain gluconeogenic amino acids are broken down into glucose. These amino acids can come from the protein consumed or stored in muscles. However, when ketones are circulating in our blood and the brain begins preferentially using ketones for the fuel, glucose requirements are reduced, therefore the need to break down muscle is reduced. This is one way ketones are muscle-sparing. The second source of glucose is from the glycerol backbone of triglycerides. Triglycerides are the storage form of fat and contain one glycerol backbone attached to three fatty acids. When the body breaks down stored fat while in ketosis, the fatty acids are detached from this glycerol molecule to make ketones, and the glycerol molecule can be converted into glucose, accounting for most of the body’s glucose requirements when keto-adapted.  Figure 1: Circulating concentrations of βOHB, glucose, free fatty acids, and acetoacetate in obese but otherwise normal man fasting for 40 days. Adapted from Cahill GF et al. Ketoacids? Good medicine? Transactions of the American Clinical and Climatological Association. 2003;114:149-163.
MYTH #3: Nutritional ketosis puts you at risk for ketoacidosis This is one of the most common myths, and despite being proven wrong time and again, people still want to believe that the ketogenic diet causes ketoacidosis. Ketoacidosis is a valid concern given that it can be a life-threatening event where ketone bodies cause a dangerous imbalance in blood pH. However, this condition occurs primarily in those with type-1 diabetes or insulin-dependent type-2 diabetes, and is uncommon in healthy individuals with a fully functioning pancreas. Blood ketone levels are regulated by insulin, just as blood glucose is. When ketones reach their upper limit (~7-8mmol/L), a small amount of insulin is released from the pancreas to help prevent any further elevation in blood ketones, this system is designed to help the body avoid what is considered ketoacidosis (~15-25mmol/L). Nutritional ketosis (i.e. ketosis achieved via a ketogenic diet) is highly unlikely to put a healthy person at risk of reaching dangerous ketone levels. There are rare exceptions to this where ketoacidosis can occur in those adhering to a ketogenic diet in instances such as dehydration, sickness, and possibly pregnancy. However, it is always advised to start a diet and/or weight management program under the supervision of a physician or healthcare provider. MYTH #4: You can’t do keto as a vegan or vegetarian The ketogenic diet is commonly associated with a diet primarily composed of animal fats. However, nowhere is it stated that to follow a ketogenic diet, solely animal fats are required. There are plenty of plant-based fat sources that are highly suitable for a ketogenic diet such as avocados, nuts and seeds, olives, etc., and their oil derivatives. For those people who are vegetarian (but not vegan), the options extend even further to include eggs and dairy, both excellent sources of fats. Incorporating oils will likely be necessary for those following a completely plant-based ketogenic diet, as it would be very difficult to fulfil the macronutrient ratios needed to enter ketosis by utilizing only whole foods. This recent post outlines different types of dietary fats that may be used on ketogenic diet, as many of the sources mentioned in the post are plant-based. There are many low-carbohydrate vegetables that should also be included in a ketogenic diet regardless of whether animal products are part of dietary intake. These primarily include leafy greens, cruciferous vegetables, lettuces, celery, cucumber, and zucchini. There are also many dairy-free alternatives to dairy fats such as nut milks, full-fat coconut milk, nut-based yogurts, and nut-based cheeses, all unsweetened of course! MYTH #5: The ketogenic diet is the same as a low-carb diet Many people begin their ketogenic diet by cutting out carbohydrates and replacing those calories with protein-based foods. Those who are used to restricting dietary fats may approach a ketogenic diet and foods with hesitation. A ketogenic diet is a high-fat, moderate-protein, very low-carbohydrate diet. So, while you may be under the allotted daily grams of carbohydrates, the amount of fats and proteins consumed must be considered as well. Fats contain ~9 calories per gram, while protein and carbohydrates contain ~4 calories per gram. Given this information, portion sizes will likely be reduced when following a ketogenic diet, and this may be more of a psychological barrier than a satiety one. Adding additional fats to meals in the form of oil, butter, ghee, or full-fat dairy can transform a low-carbohydrate meal into a ketogenic meal. Consider adding quality fats to protein sources to slow the digestion of protein and attenuate any glucose/insulin responses that could potentially prevent one from “entering” or “kicking out” out of ketosis. If you are not entering ketosis following what you believe to be a ketogenic diet, void of almost all carbohydrates, you may be over consuming protein. In this case, adjust your macro nutrients to include higher quantities of dietary fats and less low-fat protein sources. Resources:
Disclaimer: This content is not intended as a substitute for professional medical advice, diagnosis, or treatment. Individuals should always consult with their healthcare professional for advice on medical issues. Submitted by the Metagenics Marketing Team  Nowadays, thankfully, people are becoming increasingly aware that the low-fat era was one born under a false premise, yet there still seems to be a “fat phobia” lingering among the masses. To clear things up, remembering that “fat ingested does not equal fat stored” may help. This is along the lines of understanding that ingested protein does not automatically equal muscle growth.
In the metabolic state of ketosis, fat is the primary fuel source for the body, and the fat consumed contributes toward fuel for cellular function in much the same way carbohydrates act in glucose burning. Health issues associated with high-fat consumption are, more often than not, due to the combination of both high intakes of fat and carbohydrate, resembling a “Western Diet,” or “Standard American Diet (SAD),” both of which are commonly known to increase risks of obesity and insulin resistance. It is important that these should not be confused with the qualities associated with “good fats.” How did this low-fat idea come to fruition? In the 1950, an American physiologist, Dr. Ancel Keys, hypothesized that consumption of saturated fat raises blood cholesterol levels and results in increased risk of myocardial infarct or heart attack. Over the years, dietary fat was pegged as the main underlying cause for not only heart attacks, but obesity. A new, low-fat food industry was created around the ideology that the “fat you eat is the fat you wear.” Ironically, in the same time that low-fat foods entered the market, the obesity-epidemic was born 1—maybe fat was not the culprit after all? If we only consider the energy-balance equation (i.e. calories in vs. calories out) then it is easy to see how removing dietary fat would be the solution, given that fat contains 9 calories per gram, whereas proteins and carbohydrates contain roughly 4 calories per gram. What is often overlooked, however, are the hormonal responses and satiety factors, among others, associated with consuming fats, carbohydrates, and protein. Of course, calories still matter; you can’t eat more than you burn on the ketogenic diet and continue to lose weight, but it’s time to get over the misconception that consumption of dietary fat leads directly to stored body fat, without considering the other factors at play. How eating fat can lead to burning fat There are many hormones governing our metabolism, but there is one master dietary hormone, and that is insulin. Insulin is released from the beta cells of the pancreas in the presence of glucose (i.e. carbohydrates) to shuttle it away from the blood and into the cells, which lowers blood sugar levels. Insulin is also responsible for telling our cells, “Hey everyone! Glucose is available! There’s no need to breakdown fat for fuel; let’s save that for later!” In the body, carbohydrates are the primary instigator of insulin release, whereas protein only causes a very mild release, and fat causes almost no response. When glucose levels are significantly lowered, such as that achieved with a ketogenic diet, insulin requirements are also reduced. In the absence of insulin, cells can use stored fat for fuel, either directly (e.g. free fatty acids) or indirectly via the generation of ketone bodies (i.e. ketogenesis). Think of insulin as the gatekeeper of fat metabolism: When insulin is present, the gates are closed and fat is trapped inside the cell; when insulin is absent, the gates are open and fat can be broken down for fuel. Keeping your hunger in check on the ketogenic diet Besides suppressing insulin levels, the ketogenic diet is said to be very satiating, suggesting better management and control of the appetite. It can be argued that eating a ketogenic diet allows one to be more in tune with the body’s natural hunger signals. Furthermore, weight loss associated with the ketogenic diet is more often due to the natural calorie deficit that accompanies the diet since the ketogenic diet, by nature, has an appetite-suppressing effect. Leave the roller coasters for the kids! A carbohydrate-based meal often produces a rapid postprandial rise and fall in blood glucose that leaves you searching for more food soon after eating. This happens because of the dependence on glucose for fuel, and when glucose is missing from the bloodstream, it sends the signals to the body that you need food now, sending you to the kitchen. It is almost like being controlled by glucose! Following a ketogenic diet circumvents this glucose/insulin roller coaster in two ways:
The whole “fat makes you fat” myth is just that: a myth. Resources:
 Going out tonight? Going on holiday?
Dining out and going on Holiday should be relaxing, but it’s not ALWAYS easy to stick to the Ketogenic Diet. This guide will help you and your patients to maintain your Keto eating style during the holiday season. Get ready for delicious food anywhere! 1. Being Prepared 2. Your Action Plan During the Meal 3. Drinking Wisely 4. Keto on the Go 5. What to order: Different Types of Cuisine 6. Keto During the Holidays 7. How to Get Back on Track After a Cheat Meal  A ketogenic meal is comprised of approximately 10% of calories coming from healthy carbohydrates such as leafy greens, non-starchy vegetables, and limited amounts of legumes and berries; 20% of calories coming from proteins such as omega-3-rich fish and grass-fed animal protein; and ~70% of calories coming from high-quality fats such as avocado, unsaturated and medium-chain triglyceride oils, nuts and seeds, and coconut. This 10/20/70 ratio is a guideline for the macro nutrient distribution for a given day, including meals, snacks, and beverages. You may recommend a slightly modified ratio based on your physical activity and personal health goals. The diagram below highlights how the calories provided from carbohydrate, protein, and fat differs between a standard American diet and a typical ketogenic diet.  Here are some healthy Keto options:
1. What is the ketogenic diet?
Low in carbohydrates with moderate protein and high in fat, a ketogenic diet prompts the body to burn fat for energy rather than glucose, which leads to the production of ketone bodies—molecules that can be used as a source of fuel. A typical ketogenic diet consists of ~70% fat, 20% protein, and 10% carbohydrates. Though this can vary slightly depending on the individual, this diet is specifically designed to induce nutritional ketosis. 2. What is ketosis? When ketone bodies accumulate in the bloodstream (>0.5 mmol/L) due to low glucose availability, they cause a metabolic state called ketosis. The most efficient approach to induce nutritional ketosis is to lower dietary carbohydrate intake while increasing fat intake. This reduction in carbohydrate intake helps the body shift toward a state that promotes the breakdown of fats (from the diet and your body) to produce ketone bodies and enter ketosis. 3. How does the ketogenic diet differ from a paleo diet, Mediterranean, Atkins? One diet does not fit all—the best diet is the one that you can stick with for long-term. As a lifestyle modification, it should be closely monitored and modified as needed. 
4. What is intermittent fasting? How is this beneficial for someone on ketogenic diet?
Intermittent fasting (IF) limits the eating window to just a few hours a day. However, during this window, one simply eats to feel full. This practice allows the body to increase the amount of food intake at one time, and induce adaptive metabolic changes. There are many different variations of intermittent fasting,and many different reasons for doing so. Some people may experience mental clarity and focus as well as using intermittent fasting to get over a plateau. 5. What are ketones? How are they produced? Ketone bodies production in the liver is a natural process when the body increases the use of fat as the main source of fuel. This occurs during a fasting state and/or prolonged exercise, or when dietary carbohydrates are very low. There are three endogenous ketone bodies. These are acetone, acetoacetate and beta-hydroxybutyrate (βHB). When following a ketogenic diet, your brain, as well as other organs and tissues, depend on ketones as an energy source. Ketones can be measured in the blood, breath and urine, and measuring can be helpful when following a ketogenic diet or program to ensure that the desired level of ketosis is reached and maintained. 6. What is keto-adaptation? How long does it take to adapt? Keto-adaptation is the process the body goes through during the ketogenic diet as it switches to using fat as an energy source rather than glucose. The length of time varies for individuals, but typically starts a few days after being on a ketogenic diet. Within a week to two weeks, many people report positive effects of keto-adaptation, and studies have shown that signs of keto-adaptation (such as increase in fat oxidation) occur within this time-frame. 7. What are exogenous ketones vs. endogenous ketones? Are there benefits to taking exogenous ketones? Exogenous ketones are ketone bodies in either mineral or ester forms that can be ingested as a nutritional supplement, producing acute elevations in circulating ketone levels. Nutritional ketosis resulting from adherence to a ketogenic diet is often referred to as endogenous ketosis in contrast to peripheral ketosis induced by supplementation, referred to as exogenous ketosis. 8. Which patients or individuals would be excluded or not advised to follow a ketogenic diet? While the ketogenic program can benefit a wide array of patients, it may not be suitable for patients with possible inborn metabolic disorders (CPTI or II deficiency; β-oxidation defects [LCAD, MCAD, SCAD]; and pyruvate carboxylase deficiency). Caution should also be used in patients with the following conditions:
Depending on the health goals, the practitioner may recommend a specific time period for the patient to be on the ketogenic diet. There are many people and cultures that go into ketosis and stay there for a long period of time without any negative effects. 10. Can someone just dabble in keto for a few days/weeks? Can they still get benefits? While there is evidence to support the long-term use of ketogenic diets without serious side effects, there are also benefits to just doing a cyclical ketogenic diet. We encourage patients to stay on the ketogenic program for a period of 6-12 weeks as it takes some time for the body to be “keto-adapted” and for them to start seeing results. 11. During the keto-adaptation process, which noticeable changes are expected and what is the “keto flu”? During the keto-adaptation process, many people may experience symptoms of the “keto flu”. These symptoms occur because the body, being used to utilizing carbohydrates as main source of energy, is going through a metabolic shift to burn fat instead. Some people describe this as a feeling of withdrawal. Symptoms one may experience include feeling drowsy, achy, nauseous, dizzy, and irritable. Some may even experience cramping, stomach pains, and muscle soreness. 12. How long do these symptoms last? It varies for the individual, but the keto flu lasts typically a week or less for the average person and not everyone experiences the keto flu. However, below are some anecdotal ways to mitigate symptoms of the keto flu. Increase electrolyte intake, but avoid those electrolyte sports drinks with high sugar.
Ketones can be measured in a variety of ways via a breath meter, urine strips, or a blood meter. The blood meter is the most accurate way to measure the levels of ketones (primarily βHB) in the body. However, this method is more invasive than others, and can also be significantly more expensive. Your healthcare practitioner can advise you on commercially available blood meters to test ketone levels by looking at circulating levels of βHB measured in millimolar (mmol/L) units. 14. What levels should be achieved (millimolars)? While variable among individuals, βHB ranges >0.5mmol are considered the beginning of the range of nutritional ketosis and a range at which clinical benefits (for example to body weight management) have been described. Work is ongoing to understand the optimal range of circulating ketones for different outcomes. 
15. Why is it important to incorporate as we age?
The healthy young brain relies solely on glucose to obtain energy for its functional and structural needs. During healthy aging, brain glucose uptake is 10-15% lower and can be up to 35% lower in certain brain areas in neurological disorders such as Alzheimer’s Disease. In contrast, brain uptake of ketones appears to still be normal in the brains of Alzheimer’s disease patients. A common misconception is that the brain can only use glucose. Ketone bodies are the only alternative source of energy for the brain as it cannot utilize free fatty acids (FFAs). Both rodent and human studies have shown increase uptake of ketone bodies by the brain following peripheral infusion of ketones, prolonged fasting, or a ketogenic diet. They observed that up to 70% of brain’s energy demands were provided by ketone bodies available in circulation (blood) and taken up by the brain. 16. Why is it used for weight loss? Ketogenic diets that are rich in fat and low in carbohydrate induce a decrease in blood sugar and insulin levels. A reduction of circulating insulin levels causes an increase in the metabolism of fatty acids (increased lipolysis-the breakdown of lipids) from adipose tissues for utilization as energy. The liver uses FFA derived from dietary source and release from adipose tissue to oxidize and generate ketone bodies in order to meet the energy demand. Ketone bodies in circulation provide a stable source of fuel for the body and the brain, thereby sparing the need to break down muscle protein into glucose as energy supplies. A ketogenic diet encourages the burning of body fat as fuel, as well as inducing satiety between meals. Additionally, a ketogenic diet may help suppress appetite and reduce cravings. 17. Why is it used to prevent cognitive decline? With a ketogenic diet, the brain utilizes ketone bodies instead of glucose as its primary fuel source. This switch can help encourage more nerve growth factors and synaptic connections between brain cells, and result in increased mental alertness, sharper focus, and improved cognitive capabilities. 18. Why is it used for diabetes? Studies have shown that low-carbohydrate diets help support insulin metabolism in the body. This is because the absence of carbohydrates in the diet can reduce circulating insulin concentrations and contribute to glucose control. 19. Will this affect cholesterol? Isn’t this diet is too high in fat for weight loss or CVD patients? The ketogenic diet, as many diets, can positively influence body weight and cardiometabolic health and potentially improve dyslipidemia. Ketogenic diets are by design high in fat, and the type of fat is an important consideration as is the overall quality of the foods eaten within the diet. In terms of cholesterol levels, although there are studies to show that total cholesterol and total LDL cholesterol may increase on a ketogenic diets, more detailed analysis of cholesterol profile has shown the following:
20. Why do athletes use it? Low-carbohydrate, high-fat and ketogenic diets are increasingly adopted by athletes for body composition and sports performance enhancements. There is not one diet that fits all or perhaps most. The literature on ketogenic diets in athletes is limited but variable with some studies showing no negative impact and others suggesting that a ketogenic approach may not be ideal. As the science evolves in this area, current thinking is that the health status of the individual athlete and type of exercise (endurance vs high intensity) they are performing is important. For example, a ketogenic approach has been discussed as being beneficial for those participating in endurance activities, or for those who need to increase power-to-weight ratio, however specific studies in these areas are currently lacking. 21. Isn’t glucose needed for energy for workouts? Carbohydrates only go so far to sustain energy throughout the day, and especially during a workout. In ketosis, your body uses fat as fuel instead of glucose, to provide the brain with a consistent supply of the ketone bodies necessary to sustain physical performance. 22. Isn’t this diet too low in protein for my patients with sarcopenia or who are athletic? Studies show that low carbohydrate ketogenic diet is effective in body weight reduction without inducing lean body mass loss, preventing the risk of sarcopenia. Consumption of approximately 25–30 grams of high-quality protein per meal maximally is recommended to stimulate muscle protein synthesis and slow sarcopenic muscle loss. 23. Doesn’t the brain need glucose to function? A common misconception is that the brain can only use glucose. Ketone bodies are the only alternative source of energy for the brain as it cannot utilize FFAs. Both rodent and human studies have shown increase uptake of ketone bodies by the brain following peripheral infusion of ketones, prolonged fasting, or a ketogenic diet. They observed that up to 70% of the brain’s energy demands can be provided by ketone bodies available in circulation (blood) and taken up by the brain. 24. Will insulin resistant patients need to be on this diet the rest of their lives? Modifying lifestyle behaviour including weight-loss and exercise are considered to be methods in restoring the ability of tissues to properly respond to insulin. Although a ketogenic diet with low carbohydrate intake can effectively improve insulin sensitivity, the duration of diet for which these patients should be on is of healthcare practitioner’s decision. As the patient makes other important diet and lifestyle changes and maintains these healthy behaviours, it may be possible to re-introduce dietary carbohydrates (with a focus on lower glycemic index/load sources) which may be tolerated with improved insulin sensitivity. 25. Isn’t this diet too acidic? Diabetic ketoacidosis happens when extremely high levels of ketone bodies are presented in the blood (normally > 5 mM). Therefore, the blood can turn more acidic. However, during nutritional ketosis you might experience a small, transient decrease in serum bicarbonate in conjunction with mild ketosis which can be minimized by increasing electrolyte intake. Hence the need for following this dietary approach under the supervision of a healthcare practitioner and for periodic monitoring of biological parameters is recommended. 26. Do I have to restrict calories on the ketogenic diet in order to lose weight or just follow the macronutrient plan? What about if I am not trying to lose weight but just want to follow the keto diet? A caloric deficit will allow your body to mobilize stored fat deposits for energy utilization. If weight loss is not a goal, there is no need for caloric deficit and you can still get the benefits associated with the keto-adapted state of nutritional ketosis. 27. I can’t recommend this diet because less than 25g of CHO’s would be impossible for my patients to adhere to. The exact amount of carbohydrate intake to reach nutritional ketosis requires an individual assessment as several parameters need to be taken into account (gender, age, physical activity, insulin sensitivity, among others). Hence, the need for following this dietary approach under the supervision of a healthcare practitioner and for periodic monitoring of biological parameters (see question 19) is recommended. A carbohydrate intake of less than but close to 50 grams per day is acceptable for some individuals to reach a state of nutritional ketosis. 28. How do I count the carbs allowed per day? Are fibre included – do these count towards the total carbs allowed per day? When following a ketogenic diet, it is important to consider the individual when determining the total amount of carbohydrates per day. Several factors will influence the ‘carb tolerance’ of an individual, such as gender, age, physical activity and insulin sensitivity among others. As a general recommendation, you will want to start with total carbohydrates intake below 50 grams per day. This number can be reassessed after the first two weeks to optimize your individual threshold for carbohydrate intake and maximize the benefits from reaching a state of keto-adaptation. Please let us know if we can provide any further information *References available Kind regards The Amipro | Metagenics Team
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