The ketogenic diet, often called the keto diet, has gained popularity recently, but its origins trace back almost a century. "Keto" is a shortened term for ketosis, which refers to the metabolic state of burning fats (in the form of ketones) instead of carbohydrates (in the form of glucose). Ketones are produced by the liver as an alternative fuel to glucose whenever carbs are insufficient to meet energy needs. Ketosis is a metabolic state that can occur with a very low carb diet, during prolonged exercise, or after 24 hours of fasting.
Understanding Ketosis
Ketosis is not the same as ketoacidosis, a life-threatening condition that arises when ketones build up faster than they can be utilized by the body. The liver synthesizes ketones from dietary fats as well as body fat. Virtually all tissues that metabolize glucose can utilize ketones, with the exception of the liver (ironically), and the brain, which needs at least some glucose in addition to ketones. One of the biggest benefits of ketosis is that your body is almost completely reliant on fats for energy. When you eat fewer calories than you burn, part of this energy supply comes from body fat, resulting in weight loss and reduced body fat. Some research indicates that following a keto diet could result in greater long-term fat loss than a low-fat diet. This is thought to be due to increased fat burning, reduced propensity to store fat, and the increased calorie “expense” of breaking protein down for energy.
Potential Drawbacks of the Keto Diet
The most obvious drawback is you won’t be getting a lot of micronutrients from fruits and vegetables. You also have to be careful to limit inflammatory fats such as grapeseed oil, soybean oil, safflower oil, sunflower oil, and partially-hydrogenated oils found in margarine. Inadequate fiber can also be an issue with the keto diet… leading to digestive issues such as diarrhea, constipation, and compromised gut bacteria. Compromised gut flora have been linked to allergies, food intolerances, compromised immune function, and leaky gut. That said, it’s not impossible to get the recommended 25 grams of fiber on a keto diet, as long as you’re choosing low-calorie, high-fiber vegetables (cauliflower, celery, greens, lettuce, broccoli and eggplant). A normal amount of fiber will not kick you out of ketosis, since fiber doesn’t contribute much in terms of energy.
You may notice poor training performance on the keto diet, particularly with high-intensity workouts, at least until you’re “keto-adapted” about a month into the diet. A recent study showed a 7% loss of power and 15% loss of endurance for athletes placed a keto diet four days prior to the test. A different study found that “keto-adapted” athletes actually performed better on sprint tests compared to the high-carb athletes. Yet another study put athletes on a keto diet and found no difference in strength or power performance when testing vertical jump, 1RM bench press and back squat, maximum-repetition bench press, and a 30-second cycling test. Individual performance may depend on how well the person is keto-adapted, but either way, keto isn’t going to completely ruin your workouts. Losing muscle is another worry, particularly among the bodybuilding community.
Some have expressed concern that following the keto diet long-term causes poor carb tolerance otherwise healthy adults. There is little research, but the phenomenon appears to be only a temporary consequence of being “fat-adapted” versus “carb-adapted.” Keto dieters who gradually increase carbs seem to have no issue tolerating them in the long run. A more serious claim is that the keto diet causes fatty liver (mostly YouTube health “gurus”). Ketogenic diets have actually been used to slow the progression of non-alcoholic fatty liver disease (NAFLD), though it’s not a cure.
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Addressing the Misconception: Keto and Gallstones
Another misconception is that ketogenic diets cause gallstones and even gallbladder removal. In fact, cholesterol and healthy fats promote bile production and flush the gallbladder of stagnant bile, helping prevent stones. Bone loss and stunted growth have also been measured in children who followed the keto diet long term.
Getting into Ketosis
Now that we’ve covered all the bases, you may be wondering - how does one get into ketosis? Well, the faster you deplete your body’s glycogen stores (carbs stored in the muscle and liver), the faster you will get into ketosis. There are multiple ways to deplete glycogen, but first and foremost is restricting carbohydrate intake to less than 50 grams per day with at least 25 grams coming from fiber. Since your liver can make glucose from excess amino acids, you must also restrict protein intake (including amino acid supplements) to 20- 25% of total calories (30% if restricting calories for weight loss). You can accelerate the path to ketosis with intense full-body workouts, HIIT cardio, and heavy lifting to failure. All of these will deplete glycogen in both the muscle and the liver. High-intensity exercise burns up to 65% of calories from carbs, whereas low-intensity exercise burns 40% or less from carbs (at least until you’re carb-depleted, then everything shifts toward fat-burning). Four hours of moderate-high intensity exercise can deplete glycogen sufficiently for ketosis.
Now, the absolute quickest way to get into ketosis is fasting for 24 hours. You can drink water, black coffee, or consume anything with almost no calories. The most accurate way to test whether you’re in ketosis is using a blood ketone meter that pricks your finger. If that sounds unpleasant, you can use urine keto strips or a keto breathalyzer, though less reliable. Getting adequate electrolytes (sodium, potassium, magnesium, and calcium) helps counteract the loss of water and minerals due to ketosis. Electrolytes are also vital for nerve function, muscle contraction, hydration, and many other metabolic reactions in the body. To avoid digestive issues, I recommend a good probiotic (capsules, powder, or live cultures) and prebiotic fiber supplement (such as psyllium husk capsules). In addition, if you’re not getting three cups of low carb veggies in per day, a greens supplement may help replace the micronutrients and antioxidants you’re missing. MCT oil and coconut oil are excellent sources of medium-chain triglycerides (fats) that readily metabolize into energy and promote ketosis. Both can help improve energy levels while on the keto diet. The difference between coconut oil and MCT oil is the amount of caprylic acid, a fatty acid that provides almost instantaneous energy and is preferred by the brain.
Supplementing with exogenous ketones makes it easier to get high levels of ketones in your blood and enter ketosis faster, but they reduce the need to make ketones from your own body fat. One of the main reasons keto works for weight loss is because synthesizing ketones burns a lot of calories - consuming exogenous ketones does not. Other benefits of exogenous ketones, such as appetite suppression and lowered blood sugar, can be achieved with diet-induced ketosis.
Initial Challenges and Long-Term Adaptations
The keto diet is pretty rough at first. For the first week (or weeks), you will probably experience fatigue and trouble focusing as your body adapts to the lack of carbs. It’s fairly common to have headaches as your brain switches to ketones for fuel, digestive issues as your gut adjusts to the high fat intake, and diminished training performance due to depleted muscle glycogen. Don’t be surprised if you have insomnia either - carbs aid sleep by increasing serotonin and tryptophan levels. Melatonin is an effective natural sleep aid, and I’ve mentioned several supplements in the previous segment to relieve other side effects.
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Once you’re in full ketosis, you may notice fruity bad breath or “sweet-smelling” pee, which are sure signs that ketone levels are high. You should also start to feel less hungry, as ketones suppress appetite hormones and stabilize blood sugar. Dry mouth and constant thirst are also common, due to a loss of water and electrolytes. About a month into the diet, you should be feeling pretty energetic (assuming your calories aren’t too low), and begin to perform better in the gym. On the downside, you may start to miss some of those high-carb comfort foods, or become weary of saying “no thank you” to various offerings at social gatherings.
If you choose to drink alcohol during keto, just exercise moderation and choose drinks that are low in carbs (dry wine, certain beers, straight liquor). This won’t kick you out of ketosis, as a matter of fact it can actually push you further into ketosis, even dangerously so. Since alcohol is toxic, it’s metabolized first priority over ketones and other nutrients. Fats and carbs are stored under these circumstances, but ketones cannot be stored so they build up in the blood before being eliminated in your urine.
Some experts recommend transitioning into a high-fiber “cyclical” keto diet with targeted higher carb days (100-150g) for hormone balancing and muscle growth. Other health authorities suggest a Mediterranean, Atkins, low-glycemic or Paleo-style diet for weight maintenance post-keto. Personally, after two years on keto, I prefer higher carbs and intuitive eating for weight maintenance. It’s helped me put on muscle, avoid fat gain, all with enough flexibility to enjoy life.
Gallstones: An Overview
Gallstones are a common health issue affecting millions of people worldwide. These small, hard deposits form in the gallbladder, a small organ located under the liver that stores bile. In the United States alone, approximately 20 million people suffer from gallstones, with a higher prevalence in women than men. As dietary habits evolve, so does the interest in various diets like the ketogenic diet and intermittent fasting, both of which have been suggested to offer health benefits beyond weight loss, including the potential to reduce the risk of gallstone formation.
Gallstones are primarily composed of cholesterol, bilirubin, phosphates, and calcium carbonate. The most common type, cholesterol gallstones, accounts for more than 85% of all gallstones in developed countries. These stones are not simply concentrated bile; they result from complex interactions involving cholesterol, bile acids, and other substances.
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Causes and Risk Factors
Gallstones often form when there is an imbalance in the composition of bile. Excess cholesterol in the bile can crystallize and form stones, especially if the gallbladder is not functioning properly to release bile. The gallbladder plays a crucial role in concentrating and storing bile. If it is not active or functioning correctly, it can lead to an accumulation of cholesterol in the bile, increasing the risk of stone formation.
Additional risk factors include gallbladder inactivity, which can be due to obesity, diabetes, and certain medications. High estrogen levels, such as those experienced during pregnancy or menopause, can reduce the contractile function of the gallbladder, increasing the risk of gallstones. Similarly, high insulin levels, often seen in diabetes, can also contribute to gallstone formation.
Keto and Intermittent Fasting: Impact on Gallstones
The ketogenic diet is a high-fat, low-carbohydrate diet that promotes the production of ketones, which can help reduce the risk of gallstones by improving bile release and composition. Rachel Kleinman, RDN, LDN, clinical dietitian, says the keto diet is primarily used to manage seizures in children with epilepsy. Ketosis is a metabolic adaptation to allow the body to survive in a period of famine. To achieve ketosis, the diet requires you eat 75 percent of your calories from fat, compared to 20-35 percent normally. It also requires 5 percent of calories from carbohydrates, about 20-50 grams per day, and 15 percent of calories from protein. Kleinman said it takes about 72 hours for ketosis to kick in.
People following the keto diet should be eating foods like fatty fish, eggs, dairy, meat, butter, oils, nuts, seeds and low-carb vegetables. “Fat bombs” like unsweetened chocolate or coconut oil can help people reach their daily goals for fat intake. Keto-compliant foods like red meats and nuts can be costly.
The high-fat content of the keto diet can stimulate the gallbladder to release more bile, which helps to prevent the formation of cholesterol gallstones. By normalizing insulin levels and reducing insulin resistance, the keto diet may also mitigate the risks associated with high estrogen levels, such as those experienced during menopause.
Intermittent fasting, on the other hand, can help concentrate bile without causing gallstones. Fasting periods allow the gallbladder to empty and then refill, potentially reducing the risk of stone formation. Combining the keto diet with intermittent fasting may enhance the benefits of each approach, potentially reducing the risk of gallstones even further by improving bile composition and gallbladder function.
The Role of Bile
Proper bile release and composition are crucial in preventing gallstone formation. Diets that stimulate bile release, such as the keto diet, can help reduce the risk of developing gallstones.
Contrasting Diets and Their Effects
Low-fat diets may not stimulate the gallbladder to release bile, which can lead to an accumulation of cholesterol in the bile and increase the risk of gallstone formation. A diet lacking sufficient fat may not provide the necessary stimulus for bile release, potentially increasing the risk of developing gallstones. In contrast, the keto diet has been shown to help normalize insulin levels, which can reduce the risk of gallstone formation associated with high insulin levels.
Common Treatments and Misconceptions
Traditional treatments for gallstones include medications like ursodeoxycholic acid (ursodiol) to dissolve cholesterol gallstones and cholecystectomy (surgical removal of the gallbladder) for symptomatic stones. Contrary to common misconceptions, fasting and high-fat diets do not cause gallstones. Instead, they can help prevent them by promoting proper bile release and composition.
Wellness dietitian Mary Condon, RN, LDN, says the keto diet may result in weight loss and lower blood sugars, but it’s a quick fix. “More often than not, it’s not sustainable. “If you are on diabetic medication that causes low blood sugar, those meds may need to be adjusted within a few days,” Condon says.
The keto diet could cause low blood pressure, kidney stones, constipation, nutrient deficiencies and an increased risk of heart disease. Strict diets like keto could also cause social isolation or disordered eating. Both Condon and Kleinman say they wouldn’t recommend the keto diet to their patients because it is ultimately not realistic or sustainable. “There’s not one diet that’s good for everyone,” Kleinman says.
Conclusion
Gallstones are common, affecting millions of people worldwide. The risk factors include an imbalance of cholesterol and bile, gallbladder inactivity, high estrogen levels, and insulin resistance. The ketogenic diet and intermittent fasting may help reduce the risk of gallstone formation by improving bile release and composition. Low-fat diets may increase the risk of gallstones due to insufficient bile release. While dietary changes like the keto diet and intermittent fasting show promise in reducing gallstone risk, it is essential to consult healthcare providers for personalized advice.
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