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Despite the increasing popularity and the common use of the term ‘keto’ or ‘ketogenic’ to describe carbohydrate restricted diets, in our experience many of the people who use these terms to describe their daily nutrient intakes are not actually on a ‘ketogenic’ diet by objective criteria. More importantly, of those who do achieve nutritional ketosis, many are consuming poorly formulated ketogenic diets that put them at risk for unpleasant side effects and potential adverse events.

To be blunt, this can be hard for many otherwise very capable people to do on their own. It involves a complex mix of timed dietary choices, medication management, and behavioral changes that involve more than just deciding to eat fewer carbohydrates.  Thus, most people who make an earnest attempt to self-navigate a ‘keto diet’ either fail in their initial efforts due to inadequate results, preventable side effects, or ultimately give up because what worked for them initially did not prepare them for long-term success.

To promote a better understanding of what constitutes a well-formulated ketogenic diet, we have identified 10 key characteristics of both the diet and the context of its use.  They are:

  • Sustains nutritional ketosis
  • Maintains or improves lean body mass and performance
  • Effective electrolyte, mineral and hydration management
  • Long Button Cartoon Paw Shirt Front Embroidery Bear Chic Sleeve Lapel Fat provides majority of dietary energy in all phases
  • Counting calories is not necessary for success
  • Totally or predominantly composed of ‘whole foods’
  • Short-term very low-calorie diets should be avoided until proven effective in long term studies
  • Contraindicated for chronic conditions unless a credible long-term maintenance phase has been demonstrated
  • Ongoing expert medical supervision required for medication management of chronic conditions (e.g., type 2 diabetes, hypertension)
  • A well-formulated ketogenic diet does not necessarily adhere to traditional dietary guidelines

Admittedly, this list may appear a bit daunting. However, for many people, the short and long-term health benefits of nutritional ketosis (NK) more than justify the efforts needed to achieve and maintain it.  The valuable effects of sustained nutritional ketosis include reduced inflammation (1,2) and improved insulin sensitivity (3,4) — in addition to a reduction in hunger and cravings (5,6). In combination, these benefits of NK predictably lead to improved metabolic health and major weight loss. However, it is evident that getting an individual’s blood ketone level into the effective therapeutic range of 0.5 to 4.0 mM and then maintaining it there for months and years can be a major challenge.

A thorough understanding of the proper composition and management of a well-formulated ketogenic diet (WFKD) is essential in order to achieve and sustain the benefits of nutritional ketosis. In the short-term, appropriate fluid and electrolyte/mineral intakes that match the unique requirements associated with keto-adaptation are necessary for optimum well-being and can markedly reduce or prevent symptoms of the so-called ‘keto-flu’. Over the ensuing months and years, getting and keeping this formulation ‘right’ for the individual is necessary to optimize and sustain metabolic health, disease reversal (e.g., type 2 diabetes, metabolic syndrome, hypertension), and major weight loss.

It is also important to keep in mind that for individuals who start out taking medication for a major disease like type 2 diabetes and/or hypertension, a WFKD is a powerful medical therapy which necessitates day-by-day medication management by an expert physician and team to prevent dangerous drug side-effects. We strongly recommend getting medical supervision before making any dietary changes, especially if you are on medications for blood sugar or blood pressure. A physician can help you safely adjust your medications so that they don’t drive your blood sugar or blood pressure too low. Both hypoglycemic (low blood sugar) and hypotensive (low blood pressure) episodes can be very dangerous.

To further explore what constitutes a well-formulated ketogenic diet, here are concise summaries of the 10 necessary basic components and how they are utilized to optimize the benefits of nutritional ketosis and to avoid the common pitfalls of this therapeutic metabolic state.

Defining Characteristic #1: A WFKD must result in sustained nutritional ketosis.

  • Due to individual variations in carbohydrate tolerance, total daily carb intake can range from nearly 0 to 100 g/d (although tolerance of more than 70 g/d when consuming adequate protein is uncommon). Note: due to wide variations in total energy intakes in the various phases of nutritional ketosis, specifying carbohydrate as a percent of daily intake (aka ‘macros’) is of marginal utility.
  • Based upon a combination of clinical experience and known mechanisms through which the ketone beta-hydroxybutyrate (BOHB) functions as both a fuel and regulatory signal, we have defined nutritional ketosis as an average serum BOHB concentration in the range between 0.5 mM and 4.0 mM as measured by validated blood or serum assay methods.
  • Despite its reduced carbohydrate content, it needs to be tastefully prepared with adequate variety so as to be palatable and sustainable.

Defining Characteristic #2: A WFKD has to provide adequate macronutrients to preserve lean body mass and function.

  • Effective protein intakes can range from 1.2 to 2.0 g/kg-d reference weight, where reference weight is based upon sex-based standard values for height. (7,8). See protein recommendations.
  • In this protein dose range, the addition of dietary carbohydrate is not necessary to maintain lean body mass (7,9).
  • The combination of both carbohydrate and protein intakes at the upper ends of an individual’s tolerance range typically drives ketones down out of the NK range, particularly for those with underlying insulin resistance. For this reason, the best practice of a WFKD typically requires holding protein in moderation and adding just enough dietary carbohydrate to allow dietary variety and provide valuable micro-nutrients and minerals from vegetables, nuts/seeds, and berry fruit.

Defining Characteristic #3: A WFKD contains enough electrolytes and intercellular minerals to maintain optimum circulatory, muscle, and nerve functions.

  • Adequate sodium and potassium are provided to support circulatory volume and avoid potassium depletion resulting in impaired muscle anabolism or adrenal stress.
  • Accelerated renal sodium excretion associated with nutritional ketosis raises the typical adult daily sodium intake requirement to 4 – 5 g/d with exceptions for those taking medications for hypertension or congestive heart failure.
  • Magnesium depletion signs/symptoms such as muscle cramps, muscle fasciculations, and persistent hypokalemia are common in adults due to poor dietary intake combined with medication and/or alcohol effects on renal excretion.
  • Bear Embroidery Shirt Paw Sleeve Front Chic Lapel Cartoon Long Button Magnesium intake often needs to be increased by food choices or supplementation to normalize neuromuscular and cardiac functions as well as lean body mass preservation independent of dietary protein adequacy.
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Defining Characteristic #4: In all phases of a WFKD, the majority of daily energy intake will come from dietary fat.

  • Example:
    – Induction = 80-120 g/d protein, 30-50 g/d carb, 60-100 g/d fat
    – Maintenance = 80-120 g/d protein, 30-70 g/d carb, 100-200 g/d fat
  • In all phases, the majority of fat needs to come from mono-unsaturated and saturated sources from the foods themselves or as added natural fats.
  • Adequate omega-6 essential fats are obtained from whole food vegetable and animal/vegetable protein sources. Omega-6 rich vegetable oil sources should be routinely avoided whenever possible.
  • As weight loss stabilizes and glycemic control typically improves over the first year of a well-formulated ketogenic diet, it may be possible to add a small amount of additional carbohydrates back into the diet while still maintaining nutritional ketosis. In such transition periods, it will be important to test both blood ketones and blood glucose values periodically to ensure glycemic control is maintained with the addition of carbohydrate.
  • Protein remains relatively constant over this time, while fat intake may increase to meet caloric needs.

In insulin resistant adults, carbs are initially limited to 30 grams per day, then liberalized slowly while maintaining ketosis.

Daily protein prescribed in a range between 1.2 and 2.0g/kg reference weight (approx 15% daily expenditure).

Fat is consumed to satiety.

 

This graph illustrates a typical physiological weight loss response to a well-formulated ketogenic diet eaten to satiety rather than when prescribed as a rigid caloric restriction. Note that in this scenario, dietary protein is moderate and unchanged, carbohydrate is held constant or only slightly increased in a narrow range, and one’s spontaneous intake of fat increases to sustain satiety as major weight loss transitions into weight maintenance.

Defining Characteristic #5: Counting or restricting calories is not necessary for lasting success.

  • While many “diets” restrict calories in order to get results, a well-formulated ketogenic diet allows the individual to eat fat to satiety and still lose weight and improve metabolic health.
  • Lapel Embroidery Front Paw Bear Long Chic Sleeve Button Cartoon Shirt Calorie counting is not essential; however, individuals must be mindful not to eat past satiety or purposefully consume fats in excess of energy needs in an effort to increase ketone values.
  • For many people who have spent a lifetime eating a fat-restricted diet which promotes inflammation and inhibits satiety, experiencing the prompt sense of having eaten enough (i.e., satiety, not fullness) that occurs with nutritional ketosis can be a new experience. Working with a health coach and/or learning how to identify physiological satiety is important for success.

Defining Characteristic #6: A WFKD is preferably composed of all or mostly whole, unprocessed foods.

  • Choose fresh unprocessed vegetables, meats, eggs, dairy, berry fruit, and minimally seasoned nuts and seeds when possible
  • Fresh frozen choices with no added sugar and minimal processing are also encouraged
  • Fermented foods with no added sugar are allowed (e.g., yogurt, sauerkraut, pickles, kimchi).
  • Specialty frozen low carbohydrate meals can be used as needed
  • Exceptions to whole foods (electrolyte replacement)
    – Magnesium
    – Bouillon (sodium)

  • Purified protein sources, specialized fats, high potency vitamin formulations, and meal-replacement formulations (e.g., shakes, bars) in most cases should be used sparingly, but can be helpful to supplement special dietary restrictions like vegetarianism.

Embroidery Chic Cartoon Bear Button Front Long Sleeve Paw Lapel Shirt Defining Characteristic #7: Any ketogenic regimen under 1000 kcal/d (aka very-low calorie diets (VLCD)), whether from real food or a prepared formula meal, does not qualify as a WFKD due to a lack of adequate macronutrients and calories for long-term sustainability.

To our knowledge there are no published studies of sizeable cohorts fed a VLCD for up to 6 months that did not demonstrate substantial weight regain within 12 months.

Defining Characteristic #8: If intended to treat, manage, or reverse a chronic condition, a WFKD needs to have a credible maintenance phase that can be followed for years and decades.

  • For people with underlying insulin resistance in particular, a well-formulated ketogenic diet eaten to satiety frequently allows one to achieve a natural transition into a sustainable maintenance pattern of eating.
  • A short-term ketogenic diet or VLCD followed by the re-introduction of carbohydrate in amounts that reverse nutritional ketosis is seldom successful at maintaining weight loss or metabolic health long-term.
  • Long-term severe voluntary calorie restriction resulting in constant hunger is NOT a credible, sustainable maintenance strategy.
  • High volume exercise, particularly in individuals with a history of diabetes or obesity, is rarely an effective weight maintenance strategy in the absence of some degree of ongoing carbohydrate restriction (10).

Defining Characteristic #9: A therapeutic WFKD requires expert supervision and avoidance of unnecessary cycling in and out of nutritional ketosis.

  • If intended to improve diabetes or hypertension, inconsistent and intermittent restriction of carbohydrate intake alone or in combination with restriction of total calories in the context of ongoing medication use adds unacceptable risk of medication side-effects.
  • While time restricted feeding or intermittent fasting for periods less than 24 hours may be tolerated within the definition of a WFKD, any fasting longer than 24 hours, even if infrequent, is not likely to confer long-term benefits for those with chronic medical conditions (11,12).

Defining Characteristic #10: A well-formulated ketogenic diet does not necessarily adhere to traditional dietary guidelines.

  • A well-formulated ketogenic diet has characteristics that cannot be consistent with traditional dietary guidelines. Thus, it is important to realize that most prevailing dietary dogma and nutrition guidelines in developed countries are inconsistent with the characteristics outlined here.
  • A “ketogenic diet” that is very energy restricted but contains a substantial carbohydrate content (e.g., 50% or more of energy), moderate protein, and low-fat is not a well-formulated ketogenic diet (9,13).
  • Always consult with a trained physician when beginning a well-formulated ketogenic diet, especially if you have any health conditions and/or you are taking any medications.
  • To be clear, this list of defining characteristics is inclusive.  If all of these ten characteristics are not addressed correctly, it is likely not a well-formulated ketogenic diet.

Nutritional ketosis achieved by consuming a well-formulated ketogenic diet can be a safe and sustainable therapy for a variety of conditions, particularly those driven by underlying insulin resistance or inflammation. To have a lasting effect, however, in most cases the physiological blood ketone levels characteristic of nutritional ketosis need to be maintained, along with adequate intake of electrolytes and minerals. When used to reverse disease states requiring medication withdrawal, constant medical oversight during the early phases of the dietary intervention is needed.

While very restricted prepared formula or food-based diets can have dramatic short-term effects on body weight and disease reversal, these benefits have proven to be fleeting when viewed one to two years post intervention. In the end, achieving a lasting effect depends upon teaching the patient to consume a properly formulated diet composed of readily available and economical ‘whole foods’ eaten to satiety.  With attention to these 10 defining characteristics, we have demonstrated that a safe and sustainable state of nutritional ketosis is within reach for a majority of motivated adults who choose to try it (2,4).

22 Comments

  1. Thank -you. Always enjoy your well thought out and insightful articles.

    Reply

  2. I have been following a WFKD using your principles and my LDL has creeped up and now my doctor wants to put me on a statin. I have put him off for a month but what advice would you give?

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    1. We can’t give medical advice in this forum, so we recommend that you speak with your physician.

      Reply

  3. Great bulletpointed article.

    One question;
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    Many recommendations on a KD keep protein intake to 0.8g per Kg. Which can result in common blood glucose ranges between 60 and 80mg/dL or lower.

    When consuming the WFKD recommendation of 1.2 to 2g per Kg of reference weight of protein this ranges seem to be higher; What would be a normal range of blood glucose levels (fasting BG, and post prandial BG)?

    Thank you in advance for your answer.
    Xurxo

    Reply

    1. Blood glucose values depend on the individual and their unique metabolism. There’s more information on protein here: https://blog.virtahealth.com/how-much-protein-on-keto/

      Reply

  4. Embroidery Shirt Chic Paw Front Button Bear Lapel Sleeve Long Cartoon Dmac, fairly typical for LDL to go up in low carbers, but HDL also goes up and so ur ratio remains the same! Most important markers an educated Dr should look for….ur triglycerides will have plummeted and ask him/her to measure fasting insulin. Please look on Diet Dr or YouTube for all Dave Feldmans or Dr Ken Sikaris on YouTube….talks which explain this phenomena. Tell ur Dr that u acknowledge u have been offered a statin for his records but that you are politely refusing it.

    Reply

  5. Hi,

    Kudos to Virta that albeit its commercial interests keeps sharing know-how and daily applicable guidelines in a clear & concise form. Great reading! and great blog.

    I managed to reverse my T2D applying KD principles (self administrated) for 1+ year. Intuitively, I continued to restrict my carbs by both amount and type. But lately, as I engaged more in Strength Training I do have a serious dilemma between Proteins intake and NK.

    ISSN recent recommendations goes for 3g/Kg reference LBM to support muscle building. As we age protein intake is naturally more critical as GH, Testosterone and IGF-1 are naturally lower. I would be truly interested to hear VIrta’s stand on *building muscle mass and maintaining NK* at higher proteins intake. Maybe supplementatoin such as MCT (C8) or the more exotic (or awfully pricey) Exogenous Ketone Easters may do the magic.

    Best regards,
    Yuval.

    Reply

    1. Thanks for your question! Here’s a response from Dr. Phinney and Dr. Bailey:

      This is an excellent ‘nest of questions’. Here’s a brief answer for each part of this, with references to our blog where appropriate:

      1. Protein requirement for someone on a well-formulated ketogenic diet, with specific reference to the aging adult
      Answer. Jeff Volek and I have been studying this question for a couple of decades, and we cannot find convincing evidence from our research or published science by others that any adult following a well-formulated ketogenic diet needs more than 2 grams of protein per kg of reference weight. Unfortunately there is little published data from groups of people over age 65 in nutritional ketosis, but we are not aware of indications of a steeply rising daily protein requirement beyond 2 g/kg (which is already 2.5 times the standard RDA value).

      2. Need for additional protein for muscle building (aka anabolism)
      Answer. While eating enough protein of adequate quality is required for the body to maintain optimum lean tissue content, increasing one’s protein intake beyond that level of intake does not drive muscle buildup any faster. And even when there is very rapid muscle gain during resistance training, that rate of gain is rarely greater than a quarter lb per day (i.e., 2 lbs per week), and more typically about 1 lb per week. That’s about 2 ounces of lean tissue gain per day, which would require only 10% net retention of 2 a g/kg intake in a typical adult male. Thus a ‘leap’ from 2 g/kg to 3 g/kg would not benefit lean tissue gain while driving down blood ketones and putting one’s diabetes reversal at risk. The one other important factor here is eating enough total calories as fat that the body does not reduce metabolic rate or its efficiency of protein utilization. The practical test of this is to eat a well-formulated ketogenic diet to satiety.
      (For more on this topic, see our protein blog post: https://blog.virtahealth.com/how-much-protein-on-keto/).

      3. The potential benefit from exogenous ketones (salts or esters) to maintain a person’s blood ketone level in the face of increased protein intake.
      Answer: The science of ketone supplements is in its infancy, so there is lots we don’t know about their interactions with specific dietary changes. Yes, consuming ketones will raise their blood levels and force the body to burn them, but how much they can replace the benefits of the body’s own ketone production remains largely unexplored. In the meantime, take the marketing claims of commercial ketone supplements with a bit of healthy skepticism.

      More on exogenous ketones here: Short Summer shirt Graffiti Neck Print Round T Cartoon Abstract Sleeves XcaqFq

      4. The potential role of exogenous ketones to enhance muscle protein synthesis
      Answer. There is a classic concern among exercise physiologists and body builders that the low insulin levels associated with a ketogenic diet will cripple muscle protein synthesis. And indeed, in some circumstances low insulin can be a problem, as well as low testosterone. But a little known but well established fact is that a well-formulated ketogenic diet raises the blood levels of branched-chain amino acids, and this is presumably due to the body’s better conservation of these essential amino acids when ketones are present in the blood stream. Increased blood BCAA are a potent stimulus for protein synthesis. Thus our hunting and herding ancestors were not predestined to be scrawny weaklings compared to their farming cousins. In fact, what we know from studies of ancient cultures indicates that the hunters were taller and stronger than carbohydrate-dependent populations (ref: Orr 1931, Diamond 1987). But the key question is what do exogenous ketones do to blood BCAA levels and protein synthesis, and the answer is we don’t yet have the data to answer this.

      Orr J. B. ; Gilks, J. L. Studies of nutrition. The physique and health of two African tribes.
      Miscellaneous : Special Report Series. Medical Research Council 1931 No.155 pp.82 pp. ref.11

      Jared Diamond. The worst mistake in the history of the human race. 1987. http://isite.lps.org/cmorgan/web/documents/WorstMistake_000.pdf

      Reply

  6. Likely the most useful article on the big picture read to date. Thank you!

    Reply

  7. can you give me a further detail about reference weight? I still don’t understand about this ..If my height 1,67, and my current weight 78 kg, how much protein should I consume?

    Reply

    1. You can find your reference weight and protein recommendations in the table here! https://blog.virtahealth.com/how-much-protein-on-keto/

      Reply

    2. Just go to the table in the article I linked to, find your height on the left, and look at the columns that correspond to your gender. We have your reference weight and the minimum and maximum protein ranges listed.

      Reply

  8. Thaks for this great information!
    I’ve been following a keto diet for some time now, following most of the points given in this post. However, I have never measured ketones, relying instead on how I feel to let me know if ‘I’m doing it right’ – mainly hunger disappears and I have better energy levels.
    Out of curiosity, I reacently bought a cheap breathalyzer which I heard was unable to differentiate between alcohol and the acetone produced in the breath when you’re in ketosis.
    I’ve been using the device several times a day for about a week now and consistency get readings of between 0.5 and 1.0 g/l (0.05 to 0.10% BAC). This is enough for the screen to beep repeatedly and display ‘danger’ (I don’t drink alcohol, by the way) so I assume this means I’m in ketosis.
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    The rest of my family eat a ‘normal’ diet and always register 0.0.
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    What I’d like to ask is if anyone knows if the levels I’m getting on the breathalyzer are in the ‘optimal’ range for nutritional ketosis and how this level of acetone might correlate to serum BOHB?
    I’ve searched for the answer online but couldn’t find anything.
    Regardless, I’ve found this cheap breathalyser to be a quick, cheap and non-invasive way to get feedback on my dietary choises. I highly recommend it for anyone looking for an alternative way of measuring their ketone levels.

    Reply

    1. Lapel Sleeve Front Embroidery Chic Button Cartoon Paw Shirt Bear Long Virta Health August 21, 2018 at 9:48 pm

      Thanks for your question! We asked Dr. Phinney and Dr. Bailey and this was their response:
      “There are a number of breath acetone devices available on the market at a variety of prices. While large laboratory instruments using gas chromatography can determine breath acetone vary accurately, we are not aware of any hand-held home devices that do this with proven accuracy. The only effective method to assess nutritional ketosis that we know of is finger stick testing using a glucometer that also has ketone test strips (e.g., the Abbott Precision Xtra or KetoMojo devices).”

      Reply

  9. Hi there,
    I have been advised to be on an alkaline-keto diet for my endometriosis and constant fatigue. I am in ketosis but I am struggling. I would love some help with my meal plans. Have you any suggestions? I have looked up online but its very hard to come across someone to help create specific meal plans for keto?

    Reply

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      We suggest you find a registered dietician (RD) in your area, or online, that is experienced in working with well-formulated ketogenic diets so that you can get personalized assistance in developing a meal plan that meets your needs.

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      Reply

    2. Jacqueline Walburn September 6, 2018 at 1:02 am

      I am doing the same. Happy to help.

      Reply

  10. Finding a “trained” doctor locally is the equivalent of finding the Hope diamond in your backyard.

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  11. Hello, as a healthcare provider, many diets that I have seen where high levels of fat loss occurs which is important in patients there are some very Important points I want to stress. Mineral, electrolyte, B complex, certain amino acids are already deficeint BEFORE they start their program. Also extremely important is the high volume of heavy metal and chemical contaminants stored in tissue structures. I recently had a gentleman that lost 100 lbs and he had broken out in a severe rash BECAUSE of the Inability of detox organs to handle the release of toxins stored in his tissues. He had high heavy metal and chemical toxicity causing an autoimmune response which I had to handle. I decided a few years ago to produce a detox protocol which I use regularly on my patients and a formula that provides all the nutrients needed to stay hydrated. Proper rehydration and proper nutrient levels must be maintained as mentioned in this article for SAFE weight loss.
    James Stivaly LMT

    Reply

    1. I concur as a health practitioner as well. The body stores toxins in fat & other tissues that gets released with weight loss & detox pathways need to be supported.

      Reply

  12. Constance Petrovic August 30, 2018 at 12:38 am

    How do I find a doctor or a nutrienst who can help with this diet?

    Reply

    1. If Virta is not an option for you for whatever reason, we suggest you find a registered dietician (RD) in your area, or online, that is experienced in working with well-formulated ketogenic diets so that you can get personalized assistance in developing a meal plan that meets your needs. As always, medical questions or concerns should be directed toward a licensed medical provider.

      Reply

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