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The Principle Based Ketogenic Lifestyle . . . Part I

BalanceIt has been resoundingly clear to me over the last couple of weeks that there is a tremendous need for a principle based approach to a ketogenic diet.  This approach, however, must be simple.  So many of the approaches to weight loss I read about are complex and the questions that arise from these approaches are innumerable.  Losing weight should not be as difficult as putting a man on the moon.  To quote a patient recently, “If it ain’t simple, Doc, I ain’t doing it. . .”

I agree.

Any approach that requires the conversion of food to numbers or calories or exchanges becomes cumbersome, and I personally won’t follow it for more than a week.   The principle based approach should be simple and is really based upon the mantra:

Give a man a fish and he will eat today. Teach a man to fish and he will eat for the rest of his life. 

Ketogenic diets are wrongly referred to as diets.  What I’m talking about is a ketogenic lifestyle.  Simple lifestyle design should not be hard. So, what do you say? Shall we learn to fish?!

I assume that if you’re reading this article, you already understand that weight gain is not due to an over intake of calories.   Weight gain is due to hormone signals throughout the body leading to the storage of fat . . . specifically, triglycerides being taken up into the fat cells.  The hormone that independently controls uptake of fat into each fat cell is insulin.  Insulin is an essential hormone, but too much of it stimulates the adipose (fat cells) to over-stock triglycerides or essentially “get fat.”  It, actually, is that simple.  There’s really only one rule to this lifestyle: If it raises your insulin it will halt or stall your weight loss.  Write that on your hand or your forehead or in your planner, the lifestyle revolves around that one rule.

Most people start a ketogenic diet because they want to lose weight and have failed at multiple other dietary approaches. Reasons for weight control failure are often multi-faceted, but they all start with from a position of flawed understanding. The majority of approaches to weight management come from  the false assumption that weight is gained because of an over-consumption of calories or a lack of physical activity to burn excess calories.   People have faithfully been restricting calories and exercising to exhaustion since the early 1980’s to no avail. (Well, 1% of people succeed, but the rest of us failed this approach). The definition of insanity is repetitive completion of an ineffective action and expecting a different outcome each subsequent time around. If you still think that caloric restriction and exercise is successful, I’ll be shipping your drawstring white vest and your invitation to a padded cell shortly.

Let me put it clearly.  We’ve been exercising and cutting our calories since 1975 and look at what it’s gotten us . . .

Obesity Trends 2015

. . . . a country that is now recognized as the “United States of Corpulence.”  Super-Size me has become literal. “Houston . . . we have a problem . . . !”


The rule above is based on foundational principles.  Understanding of the principles allows one to successfully apply the rule above.


The first principle in a ketogenic lifestyle is understanding that the problem is not caloric, but hormonal.  Choices and actions from here on out must be based on this understanding.  Anything that will raise insulin will thwart ketosis. Insulin stimulates lipoprotein lipase, the enzyme that pulls the triglycerides into the fat cells. Without insulin, we don’t gain weight. (That’s why type I diabetes are usually very slender and skinny).

The standard lab value for normal fasting insulin levels reflect 10-22 uIU/L as the normal.  However, in my office, glucose tolerance tests and postprandial glucose tests consistent with impaired fasting glucose are routinely positive when the fasting insulin level is >5 uIU/L.

Point of Focus: If your having trouble, look at the hormones.  Food stimulates hormone responses. Focus on the hormone response to your diet.


A ketogenic diet is one where the body uses fatty acids as the primary fuel. Those triglycerides mentioned above are made up of three fatty acids linked to a glycerol molecule.  To use the triglycerides, the three fatty acids must be broken away from the glycerol by hormone senstive lipase (HSL).  Insulin directly inhibits HSL. Keeping insulin levels low is the first step in shifting to a ketogenic metabolism. Lowering insulin allows access to the fatty acids in your fat cells.  Triclycerides are not water soluble and the rate by which they can be taken up and burned in the mitochondria limits the speed by which triglycerides can be used as fuel. The by product of triglyceride burning is ketones.  Ketones themselves can be used as fuel and over 4-6 weeks, the body can enhance its ability to use ketones when fat is the primary fuel. This is called “Keto-Adaptation.”

Point of Focus: Too much carbohydrate or too much protein in the diet shifts the body from the use of triglycerides.  In general, to become “keto-adapted,” limit carbohydrate to < 20 grams per day.  Keep protein < 1.0 grams per kilogram of ideal body weight for women and <1.5 grams per kilogram of ideal body weight for men.

KetoOS – Drinkable Exogenous Ketones


Wait a minute!? Where do the ketones come in? When fatty acids are burned or oxidized in the mitochondria of cells within the liver, they are converted into Acetyl-CoA.  The Acetyl-CoA is used to form ATP for energy in the Citric Acid Cycle.

Metabolism macronutrients

IF excess Acetyl-CoA production occurs or if inadequate oxaloacetate is present, the extra Acetyl-CoA is transformed into ketone bodies – specifically beta-hydroxybutyric acid and acetoacetic acid.  Fat can be oxidized or burned for fuel while ketones are being produced.  Ketones are much smaller molecules and can more easily be transported in the blood than triglycerides, as they are water soluble. The ketones themselves can also be used or burned as fuel as the body upregulates the mitochondria’s ability to use the ketones as fuel as well.  As I mentioned above, this process of “keto-adaptation” can take 4-6 weeks. Keto-adaptation results in humans having a greater desire to be physically active – the miraculous conversion of the couch-potato into the bacon-burning triathlete.

Point of Focus: Sugar is a drug.  Its byproduct has the same hedonic effect on the brain as morphine.  Sugar withdrawal can commonly cause headache, anxiousness, insomnia, dizziness, fatigue and moodiness within the first week of carbohydrate restriction on the road to keto-adaptation.



For the average person to become “ketotic” or reach a state of ketosis, it takes lowering the carbohydrates to less than 20 grams per day (and sometimes less than 10 grams per day) for at least 3-7 days.  Yes, it can actually take a week to reach ketosis.  I have a few patient’s that are so insulin resistant that it takes longer.  This means that to reach that fat burning state, one must maintain a low insulin response by restricting starch or carbohydrate intake to less than 20 grams per day for a minimum of a week.  For your body to efficiently use the fuel it can take up to 6 weeks.  This is why many people state that they “don’t feel good” or “can’t maintain their exercise levels” when starting a ketogenic diet. For most people, once they reach the 6 week mark, mitochondria have been unregulated and “fine tuned” to burn ketones, fat burning becomes efficient and energy levels begin to increase. In fact, for many like myself, you’ll finally feel like exercising for the first time in you life.

Point of Focus: If you’re already exercising, don’t be surprised if you feel more sluggish for the first four weeks.  If you’re not exercising, I don’t recommend starting until after you pass through the Keto-Adaptive phase.

MIchelin Tire Man Pondering


Clinically, the average patient in my office will lose 5-15 lbs each month for the first three months. Then the weight loss will slow to 2-5 lbs per month. However, 1/2-1 inch continues to disappear off the waist circumference measurement every month.  THIS IS NORMAL. Continued weight loss of 15 lbs a month will leave you looking like the Michelin Tire Man – rolls of skin without fat. The body slows the weight loss to keep up with skin and connective tissue remodeling.  As long as ketosis is maintained, the fat will continue to melt away.  At this point, I’m not so worried about scale weight as I am your waist circumference.

Point of Focus: Successful ketosis does not always affect the scale, but usually causes your pants to fall down.


It has been my experience that it takes about 18 months for the average patient to reverse the insulin resistance while following a carbohydrate-restricted, high-fat ketogenic lifestyle.  There is no quick fix for this. If there was, I’d be sitting on a beautiful beach in the Caribbean.

Point of Focus: The Ketogenic dietary lifestyle is actually the antidote to insulin resistance, diabetes and the diseases of civilization.


Improvement in insulin resistance has also been demonstrated with mild to moderate intensity resistance exercise.  Moderate intensity resistance exercise is 20-30 minutes of exercise like walking, easy jogging, cycling, lifting weights, yoga or Pilates with speeds or weight heavy enough to break a sweat, but not so fast or heavy that you cannot carry on a conversation with your exercise partner.  Exercise improves insulin resistance – BUT IT DOESN’T CAUSE WEIGHT LOSS!  Yes, I know, Jack LaLanne just rolled over in his grave.  But, let me say that again.  Exercise improves insulin resistance, but it does not improve weight loss!! The three largest and most intensive studies of exercise involving over 67,000 people demonstrate that you can exercise till the cows come home and you’ll average about 1% weight loss.  If you exercise, realize it WILL make you hungry.  Eating the wrong food (carbohydrate containing foods) will stimulate insulin release causing your exercise to be fruitless (Actually, your diet should be “fruit-less” anyway)

Point of Focus: Exercise because you feel like it, it improves insulin sensitivity and it decreases stress, not for weight loss.


If you are eating enough fat, you won’t be hungry. Although this doesn’t always hold true in the case of patient’s with lepin resistance.  40-60% of patients with insuiln resistance have a concomitant leptin resistance (see the article on lepin resistance here).  A ketogenic diet is one in which 50% or more of total calories come from fat.  No, you don’t have to count calories, just pick foods that contain 45% fat or more.  Look for grass fed products as they will be higher in Omega 3 fatty acids.  Red meat is 55% fat. Pork is 45% fat. This is where the chicken salad or turkey wrap fails (see Why Does Your Chicken Salad Stop Weight Loss).  Look for alternatives to replace your basic meals and snacks.  If you love chips, try pork rinds or make chips from fried cheese or pepperoni.  Guacamole is a great replacement for bean dip.

Point of Focus: There is no need to eat 3-6 times per day.  As you increase the fat in your diet you will feel more full.  Eat when you are hungry, whether that is 3 times a day or once day, listen to your body.

Adapt Your Life


I’ve been following a ketogenic diet for over 10 years.  The most common complaint I hear is,  “Dr. Nally, I’m tired of eating eggs.”  Ketogenic diets don’t have to be boring. There are hundreds of resources on the web for spicing up your ketogenic diet. See the Recommended Sites page above for some ideas to start. The Ketogenic Cookbook by Jimmy Moore and Maria Emmerich is a recent edition to the literature and a fantastic resource. Check out Franziska Spritzler’s Low Carb Dietitian website and new book as well. If you live in the UK, you should see Emily Maguire’s website and blog.  She just completed a world tour, sampling all the low carbohydrate foods and restaurants around the world.  If you are a picture person, check out the Best Keto Meals of 2015 pintrest page followed by almost 16,000 people.  If you haven’t takent the time, you should visit Dr. Andreas Eenfeldt’s website.  He is one of Sweden’s premier ketogenic doctors has an immense number of resources at his website, Diet Doctor.  Finding someone that can help you fine tune your diet is also essential.  You can find a list of doctors that use ketogenic diets here.

Point of Focus: This lifestyle will require you to use real, whole food and cook like your grandmother or great grandmother did in the past.  Unfortunately, we’ve lost a great deal of the art of cooking that needs to be re-discovered. If your lifestyle is too busy to cook and prepare real food, that busyness is probably causing you stress, another culprit in the weight gain cycle.  The truth will set you free, but it will probably make you miserable first.


WARNING!  A very sweet patient of mine was given these instructions to treat her weight and blood sugar abnormalities.  She applied these principles and they worked marvelously.  She called me a few weeks later, however, mad as a wet hen.  She placed her husband (not my patient at the time) on the same dietary changes.  Her husband, who had significant blood pressure problems and was on four different blood pressure medications I later found out, had a sudden drop in his blood pressure and passed out.  As happens to many of my patients, blood pressure, ejection fraction of the heart and blood sugars quickly begin to normalize.  However, he never saw his doctor and never had is blood pressure medications adjusted.  Because of the normalization that can occur in as rapidly as 1-2 weeks, the medications became much too strong, he passed out and ended up in the emergency room. These dietary principles are effective. They are often just as powerful as a number of the medications that we routinely prescribe.

Point of Focus: Please see your doctor before beginning any of these dietary recommendations, especially if you have any underlying medical conditions including Hypertension, Diabetes, Congestive Heart Failure, Coronary Artery Disease, Gout, Kidney Stones, etc., please do not try the dietary changes alone.  Find a physician trained in the use of this type of dietary lifestyle in combination with close monitoring of your blood pressure, blood sugar and other key vital signs.

Stay tuned for Ketogenic Principles . . . Part II in the series where we’ll address Food Psychology, To Cheat or Not to Cheat, and Keeping it Real . . .