Overcoming stumbling blocks on a ketogenic diet: a case study

I had a client contact me for an email consultation this week. She was frustrated as, despite following a ketogenic diet (where carbs are restricted to 30g or below, over 70% of calories should come from fat, and protein is moderated), she was unable to get into ketosis.

I had a look at her food diary and could quite quickly see where I thought she could change things to help enhance her ketogenic approach. With her blessing, she’s allowed me to share this with a wider audience. Like many things, if one person is having challenges finding the right balance in their diet, there are likely many more people doing very similar things and potentially experiencing the same frustrations.  I focused on some of the main issues I saw.

You’ll notice there are foods that don’t align with ketogenic diets OR would be included in any diet for someone wanting to shed fat. We (the client and I) spoke on that in general, as clearly she knows this (i.e. cheesecake). The points I focused on were those that can trip people up that she might not be aware of. I’ve screenshot her food diary, and then my comments are below.

Her diet:


Major points – unable to get into ketosis despite sticking to under 30g carbohydrate per day. This is measured by a blood ketone meter, and she wondered if she needed to add more fat to do this. Her overall goal is weight loss.

The thing with weight loss and the ketogenic diet, if you follow the advice from Phinney and Volek, pioneers of the ketogenic diet space, part of the energy your body needs to consume should come from your own fat stores, and not be provided for by diet. It’s a common misconception, as I see many people embark on a ketogenic diet for fat loss purposes but the opposite occurs – they gain weight. A common strategy at this point is to further reduce carbohydrate intake and bump up the fat. However, this will often further exacerbate weight gain (and frustration around the approach). Worst case scenario here is when the frustration leads to ‘to hell with it’ and that low carb diet is supplemented with all manner of processed refined carb junk food because ‘what’s the point? I can’t do this anyway, I’m useless and it’s not working for me.’ Clearly the end result of this self-punishment is further fat gain, some horrible carb cravings and a bad psychological state. Needless to say, I don’t think adding in more fat is the answer in this instance (and for this client), however I do think that tweaking what she is already doing is going to help.

It’s also good to remember that blood ketones aren’t the be all and end all – these indicate ketones in your bloodstream but sometimes, when these are low, this just means we are using them for energy – which is what you want! This is more likely to be the case in an athlete rather than anyone who is generally just active. In this case example,  I think the diet is the main reason for her not being in ketosis, rather than that the client is using ketones efficiently. However,  it is worth remembering that if you are following a ketogenic diet and are not seeing the expected results on the blood ketone meter.

Finally (and something I mentioned to the client) you don’t need a ketogenic diet to successfully lose weight, and sometimes focusing instead on the pointers I give at the end, regardless of ketosis, will give the same end result. Something like my online menu planner and individualised nutrition coaching. However, I would recommend in that instance to up the protein (double the recommendation I give you) and drop back the fat intake, as people often find that far more satisfying and easier to adhere to – which ultimately is THE most important thing with any dietary approach.

Key issues I picked up:

  • Too much protein in one sitting/in general
  • Processed foods
  • Dairy
  • Unintentional free sugar

1.Milk –  both the sugar in a cup of milk and the protein (whey) will raise insulin levels, thus put you out of ketosis. This is true of skim and standard milk.

2. Protein cookies: the type of sweetener/fibre used to make it a lower carb item can also spike insulin. For some people it is definitely a dose response thing going on – they can eat ½ cookie no problem, but a whole one will kick them out of ketosis. For any items like these, and if you do have blood glucose or blood ketone meters, it can be good to get a reading after a certain dose to see what effect they have for you. At any rate, highly processed goods can still negatively impact on blood sugar and appetite regulation in the absence of them being carb-based.

3. Coconut water – contains 3g sugar per 100ml or thereabouts. Any amount of free sugar in the diet is going to impact pretty quickly on your blood sugar levels if you haven’t just finished exercising, and kick you out of ketosis. The types of carbs you want to be having in your diet are specifically non-starchy carbohydrates -the majority of any carb sources coming from green leafy vegetables, other colour vegetables, perhaps some pumpkin/carrot depending on their effects on your blood sugar.

4. Grapes: any fruit is going to impact on your blood sugar levels, and particularly grapes – even if you stick within your limit of carbohydrate, the sugar from these are going to hit your bloodstream pretty quickly and cause an insulin response, thereby lowering ketones, especially if eaten outside of a meal that contains fat and/or protein (both of which slow down the glucose from hitting the blood stream). Fruit is typically best avoided on a ketogenic diet, aside from lemons, grapefruit, some berries.

5. Protein content of meals: for most, these need to be lower unless an individual is athletic. If struggling with getting into ketosis, it can be good to lower protein consistently to 1g/kg ideal body weight. For this particular client, this is 65g per day. Many days are consistently above this. In addition, the amount of protein in any one meal makes a difference – ideally, not more than 30g protein in any one sitting and, for you, likely 20g in a meal. This is obviously going to differ from person to person – as mentioned, athletes who have a greater energy output can generally get away with more protein (and more carbohdyrate) compared to a person who is sedentary or just lightly active.

6. Timing of food: eating within a restricted window (and not eating later in the evening) can help a ketogenic diet – our liver’s ability to metabolise carbohydrate is dictated in part by a ciracadian rhythm;  we are naturally more carbohydrate sensitive in the AM, less so in the PM, so carbs are likely to spike insulin more in the evening. In addition, fasting naturally upregulates ketone production and can help accelerated ketosis. Further, snacking can (for some) keep them from being out of ketosis, so 3 meals, or 2 meals plus a snack is recommended.

Key recommendations:

1. Drop protein down in each of the meals so you are averaging approximately 20-25g at meals.

2. Time any foods that have a greater amount of carbohydrate in them for after exercise (ie lower sugar fruit, or nuts that have a higher carb count such as cashews). The body doesn’t need to rely on just the action of insulin to deliver carbohydrates to cells in this instance, as we have receptors called GLUT-4 receptors in our muscles and in adipose tissue that can take up carbohydate and are activated post-exercise. Remember, an increase in insulin suppresses the production of free fatty acids, the precursors to ketone bodies.

3. Engage in exercise to help upregulate ketone production – aerobic/weight training.

4. Fasting for 14h at a time to help body produce ketones. Now for women, fasting can be a great tool, but can also backfire (read more about that here). Generally speaking, the fasting approach can be something that is incorporated 1-2 x per week if fat loss is a goal, and on other days, opt for a 12h window between dinner one night and breakfast the next day. The most important thing, though, is to be aware of negative changes to energy, how you feel, mood and sleep patterns – all underlying signs of a stress response that you might not be able to cope with.

5. Focus on diet quality – so the carbs, protein, fats are coming from whole foods and not processed or snack foods – ie protein cookies, fat bombs etc

6. Remove drinks / foods that contain easily digested carbs even if they fall within the carb count for the day. You’ll feel far more satisfied (and it is far more nutritious) to get your carbohydrates from green leafy vegetables which also contains a good amount of fibre.

7. Dairy – stick to hard cheeses and forgo the softer cheese/milk.

These are just some pointers from this client’s diet; another practitioner may pick up others. I will reiterate my point, however, in that a ketogenic diet, when done purely for weight loss, isn’t always the best approach and, for alot of people, unsustainable and too much like hard work. If you’re struggling to get the balance right and not seeing the results, then there are definitely other alternatives out there – one which will fit your lifestyle, eating behaviour, budget and allow you to lose weight with far less effort. It’s adherence that is key. Let me help you with that.

Selection of healthy fat sources

Delicious, nutritious food regardless of your dietary approach.

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