The ketogenic diet, often called "keto," has gained popularity as a dietary approach for weight loss and metabolic health improvements. Many women have achieved their goals using the keto diet, such as weight loss, controlling carb cravings, or having better energy throughout the day. While the basic mechanisms of burning fat and producing ketones are the same for both sexes, there are important differences and considerations for women, primarily revolving around reproductive health.
What is the Keto Diet?
The keto diet is a low-carb eating plan where less than 10% of daily calories come from carbohydrates. For most individuals, this translates to around 30 grams of net carbs per day, although highly active people may tolerate more. The majority of calories come from fat and protein, with healthy fats like olives, nuts, olive oil, avocados, butter, and animal fat making up a significant portion. While maximizing ketone production might require a specific protein intake, prioritizing satiety and maintaining muscle mass is crucial.
Keto and Women's Health: A Nuanced Perspective
The keto diet is not inherently sex-specific; however, women's reproductive cycles are sensitive to calorie restriction.
Calorie Restriction and Reproductive Health
A significant concern for women on keto is unintentional calorie restriction. A woman’s reproductive cycle is highly sensitive to calorie restriction, which could disrupt her cycle. While reducing calorie intake is necessary for fat loss, it's crucial to avoid excessive restriction that can negatively impact the menstrual cycle.
Keto During Pregnancy and Breastfeeding
When a woman is pregnant or nursing, she needs more calories, not less. Calorie restriction can lead to negative consequences for both mother and child.
Read also: Risks of Keto Diet
Another reason keto may be suboptimal during this time? It minimizes insulin, a key growth-promoting hormone. Low insulin is great if you’re trying to burn fat, but not so much if you’re nourishing a baby.
Keto and Menopause
During this time, estrogen levels plummet, frustrating symptoms (hot flashes, night sweats, mood swings, etc.) can flare, and fat may accumulate around the belly.
The effects of keto during menopause are individual. It could add unnecessary stress, but I think this is highly individual. I’m hesitant to recommend keto for women struggling with menopause. In the low-carb community, you may find a lot of perimenopausal women rocking a ketogenic program. So again, I think this is a case of knowing yourself and staying aware of whether or not something is working for you or not.
Keto can help with weight loss after menopause. For many of them, it works. The evidence isn’t in short supply. Some of these benefits may only apply if you’re transitioning from a high-sugar diet. Keto might not make a huge difference.
Still, keto may be worth playing with if you’ve hit a weight loss plateau, want to see how your brain runs on ketones, or are curious how ketosis affects your energy.
Read also: Meal replacement guide for women
Practical Tips for Women on Keto
If you decide to try a ketogenic diet, here are a few pointers to help you succeed:
Prioritize Adequate Calorie Intake
On the keto diet, your appetite is naturally suppressed. It can lead to irregular periods, hormonal disruptions, and other problems with your cycle. It’s important to listen to your body. More fasting is not inherently better by any means. The solution isn’t to mainline cashews 24/7, but rather to eat well at mealtimes.
When you compress your feeding window too much, it’s hard to squeeze in enough calories. Go keto first and ease into fasting slowly, working your way up hour by hour. Somewhere between 13 and 16 hours is usually about right. See what works for you.
Don’t Skimp on Protein
This is the biggest mistake that I see women making on a ketogenic diet. They cut the carbs, load up on fat, and skimp on protein. Then they lose muscle and struggle to stay active.
It’s understandable. To get 60% of your calories from fat and 30% from protein sounds like a plate full of fat, right? It’s not. Since fat has 9 calories per gram and protein only has 4, there should be a larger volume of protein on a 60/30 plate than calorie-dense fat. Don’t skimp on protein. Every day we hear how much it’s helping people. It’s gratifying.
Read also: In-Depth Look at BCAAs and Female Weight Loss
Emphasize Whole Foods
If you’re going to do keto, do it right. You might lose weight, but you won’t do your long-term health any favors. Clean keto is simple. Plus they taste better than processed junk anyway!
Maintain Flexibility
Doing everything right on keto? Still not working for you? That’s okay. Maybe you need to bring back carbs. Keto isn’t the best diet for everyone. As I mentioned earlier, I function best on a Paleo template that includes 50-75 grams of carbs per day. Don’t force keto if it’s not working. Be flexible with your diet and gentle with yourself.
PCOS and the Ketogenic Diet: A Promising Avenue
Ketogenic diet has recently made a comeback as a part of lifestyle and dietary modifications in patients with polycystic ovary syndrome (PCOS). Polycystic ovary syndrome (PCOS) is a complex multisystem disorder that shares similar pathogenesis with other chronic diseases with genetic-environmental interaction. PCOS remains the most common endocrine disorder in women, with colossal economic impact to the nation.
Recently, ketogenic diet has been making a comeback due to its potential to delay aging and as an effective fat burner. It is seen as a potential dietary intervention to help women with PCOS to lose weight and maintain weight loss, improve sex hormones level (hence fertility), optimize cholesterol level, and normalize the menstrual cycle. Ketogenic diet is characterized by low daily carbohydrate intake of below 50 g (the daily recommended carbohydrate allowance is 130 g/day) with varying amounts of allowable fat and protein, calculated based on ideal body weight.
Despite the suggested promising effects of ketogenic diet in women with PCOS, the evidence was relatively patchy, conducted in a heterogeneous setting in a small population and over a short time period. Therefore, our study aimed to assess the effects of ketogenic diet on reproductive hormone levels among women with PCOS: luteinizing hormone to follicle-stimulating hormone (LH/FSH) ratio, sex hormone binding globulin (SHBG), progesterone, and free and total testosterone level, following at least 45 days of intervention with ketogenic diet.
Impact on Reproductive Hormone Levels
Following ≥45 days of intervention with ketogenic diet among women with PCOS, significant improvement was observed in reproductive hormone levels, with reduced LH/FSH ratio (d −0.851; 95% CI −1.015, −0.686; P < .001), reduced serum free testosterone (d −0.223; 95% CI −0.328, −0.119; P< .001), and an increased in serum sex hormone binding globulin (SHBG) (d 9.086; 95% CI 3.379, 14.792; P = .002).
The pathophysiology of PCOS closely relates to an abnormality in the hypothalamic-pituitary-ovarian or adrenal axis with disturbance in the secretory pattern of the gonadotropin-releasing hormone (GnRH) that results in the relative increase in LH to FSH ratio. In healthy women, the LH to FSH ratio usually lies between 1 and 2, whereas this ratio becomes reversed in women with PCOS, reaching as high as 2 or 3. An excess in serum LH stimulates ovarian androgen production, whereas a relative deficit in FSH further impairs follicular development. Hence, as a result of raised LH/FSH ratio, ovulation does not occur in women with PCOS. In this study, we found that a ketogenic diet significantly reduced the LH/FSH ratio.
Apart from reducing LH/FSH ratio, our study also found that a ketogenic diet reduced the level of free testosterone in women with PCOS. In PCOS, hyperandrogenism is attributable to increasing levels of circulating free testosterone due to increased steroidogenesis from proliferation of ovarian theca cells resulting from an imbalance in LH/FSH ratio.
On a related note, serum SHBG is a glycated homodimeric plasma transport protein that positively correlates with the total number of follicles in women and is currently considered a biomarker for metabolic disease. Specifically, women with PCOS who are overweight or obese characteristically have a decreased serum SHBG concentration and increased serum total testosterone and free androgen index. Dietary modification with ketogenic diet was found to increase the level of circulating SHBG and hence improved metabolic and ovulatory dysfunction in women with PCOS.
The low-carbohydrate ketogenic diet was speculated to result in reduction in hyperinsulinemia and therefore decreased stimulation of ovarian androgen production as well as increased SHBG levels, synergistically limiting the circulating free androgens.
Our pooled analysis did not find any changes in serum progesterone level following intervention with ketogenic diet. However, the number of subjects available for pooled analysis were small; hence, this finding needs careful interpretation and reassessment when more studies become available. Serum progesterone is initially produced by corpus luteum upon successful ovulation to prepare the uterine lining for implantation. In general, women with PCOS are anovulatory so serum progesterone levels are low.
Weight Loss and Metabolic Benefits in PCOS
Our secondary outcome measurement was evidence of weight changes with a ketogenic diet. All included studies noted significant weight loss following very low-carbohydrate, ketogenic diets. Nutritional ketosis formulation induces weight loss through the following hypothesized mechanisms: reduced appetite due to higher satiety effect of proteins in ketogenic diet formulation, a possible direct appetite-suppressant property of the ketone bodies, reduced lipogenesis and increased lipolysis, reduced resting respiratory quotient and, therefore, better metabolic efficiency when consuming fats, and increased in the metabolic costs of gluconeogenesis, together with the thermic effect of high dietary proteins.
Despite the known positive effects of ketogenic diet in improving insulin resistance, improving sex hormone imbalances and metabolic health, and improving body composition, it is important to look at the baseline characteristics of the study participants when evaluating the effects of ketogenic diet, as they can have a significant impact on the transferability and applicability of the results. Demographic and baseline clinical parameters, such as the gender, weight, BMI, age, and health status (such as comorbid liver or kidney derangements) will impact the risks and benefits of a ketogenic diet. It is also worth highlighting that not all keto studies can be generalized for PCOS due to these potential confounding factors. Furthermore, there is no specific formulation that is tailored for PCOS; in addition, induction of nutritional ketosis may be hard on gut health and some might consider the diet as too demanding, eventually affecting long-term compliance.
Potential Benefits of Keto for Women
Weight Loss and Body Composition
There has been anecdotal evidence of people losing weight on the ketogenic diet. People also report feeling less hungry than on other types of restricted diets. The keto diet allows many people to eat the types of high-fat foods that they enjoy, such as red meats, fatty fish, nuts, cheese and butter, while still losing weight. The ketogenic diet’s ability to promote weight loss and improve body composition makes it a valuable tool for women struggling with weight-related health issues.
The keto diet helps reduce seizures in children with epilepsy. Endurance athletes and body builders also use it to scrap fat in short timeframes. The keto diet is being studied for reducing symptoms for patients with progressive neurological disorders like Parkinson’s disease.
Blood Sugar Control
People with high blood sugar, including those with type 2 diabetes, may be attracted to the keto diet because it limits carb intake to less than 10% of total calories.
Potential Anti-Cancer Effects
Following a ketogenic diet increased blood levels of ketone bodies and lowered levels of insulin-like growth factor 1 (IGF-I), a hormone that may promote the spread of cancer cells.
The researchers acknowledged that this change, along with the decrease in blood sugar seen in those following ketogenic diets, creates an inhospitable environment for cancer cells that may suppress their growth and spread. Research also shows that the ketogenic diet may improve physical function, increase energy levels, and decrease food cravings in people with endometrial and ovarian cancer.
The ketogenic diet has also shown promise when used as a treatment alongside standard treatments like chemotherapy for other cancers that affect women, including glioblastoma multiforme, an aggressive cancer that affects the brain.
Improved Energy Levels and Mental Clarity
Many women report increased energy and mental clarity while following a ketogenic diet. This is particularly beneficial for women balancing work, family, and personal health, as consistent energy levels and improved focus can enhance productivity and overall quality of life.
Risks and Considerations
Nutrient Deficiencies
“Because the keto diet is so restricted, you’re not receiving the nutrients - vitamins, minerals, fibers - that you get from fresh fruits, legumes, vegetables and whole grains,” says Dr. Ring. People report feeling foggy, irritable, nauseous and tired. “In particular, low fiber intake can disrupt gut microbiota and lead to chronic constipation, while inadequate magnesium, vitamin C and potassium can contribute to muscle cramps, fatigue and weakened immune function,” explains Dr.
One study suggests that low-carb diets are often associated with low thiamin, folate, vitamin A, vitamin E, vitamin B6, calcium, magnesium, iron, and potassium.
Potential Impact on Heart Health
The high-fat nature of the diet could also have negative impacts on heart health. The American Heart Association recommends limiting saturated fat intake to less than 6%. “In practice, many people eat high amounts of saturated fats, which could increase your risk of heart disease,” says Dr. Cheema. “You may be eating a lot of fatty meat thinking it’s a good thing for you because it's high in fat. This can dramatically alter your lipid profile. While high-fat diets can elevate LDL (“bad”) cholesterol, the type of saturated fat matters. The bottom line is that having more fats in your diet can lead to higher cholesterol. “We know that higher cholesterol tends to increase your chances of heart attacks and strokes,” says Dr. Cheema.
Depending on the composition of the diet, ketogenic diets are likely to affect heart health risk factors differently. For example, a ketogenic diet high in saturated fat is more likely to raise LDL cholesterol than a keto diet primarily composed of unsaturated fats.
Kidney Problems
The keto diet may not be appropriate for everyone, specifically people with kidney disease. “Although more research is needed in that area, there is some suggestion that it can make kidney disease worse over time,” says Dr. Some people also experience dehydration on the keto diet because they’re eliminating glycogen, which holds water, from the bloodstream.
Psychological Distress
When you micromanage your food intake by tracking how much you eat, it disconnects you from what your body is asking for. You start using outside numbers to determine what to eat instead of listening to your body. “Being intuitive and understanding what your body needs is essential for proper nourishment,” says Merneedi. Monitoring food so closely can lead to psychological distress, such as shame and binge eating.
Blood Pressure and Blood Sugar
The keto diet can cause your blood pressure to drop in the short term due to a reduction in blood volume and changes in your fluid balance. Symptoms of low blood pressure include dizziness, lightheadedness or fainting, especially when standing up quickly. Following a keto diet can also cause your blood sugar to drop, which can be dangerous for people living with diabetes. Common symptoms of low blood sugar include weakness or shaking, sweating, a fast heartbeat and dizziness.
Not Suitable for Everyone
Due to its restrictive and hard-to-maintain macronutrient ratio, the ketogenic diet isn’t appropriate for many people.It isn’t recommended for people who are pregnant or nursing or who have certain underlying conditions. This includes:
- liver or kidney failure
- alcohol or substance use disorders
- type 1 diabetes
- pancreatitis
- disorders that affect fat metabolism
- certain nutritional deficiencies, including carnitine deficiency
- a blood disorder known as porphyria
Keto Flu
The ketogenic diet can cause unpleasant symptoms known collectively as the keto flu during the adaptation phase of the diet. Symptoms include irritability, nausea, constipation, fatigue, and muscle aches.
Alternatives to Keto
For long-term weight loss, Dr. Ring, Dr. Intermittent fasting is an approach that allows you to receive the benefits of ketosis while still eating a varied and balanced diet, says Dr. Ring. By cycling between periods of eating and fasting, your body enters “mild ketosis” during the fasting phase. “Unlike the keto diet, which requires strict food restrictions, intermittent fasting lets you enjoy a variety of nutrient-dense foods, such as fruits, vegetables, whole grains and legumes, during eating windows,” Dr. Ring explains.
Dr. Cheema advocates making small changes based on your health goals. “People tend to burn out on those big goals and challenges, and then they go back into their own habits,” he explains. “Just because you were super fit between the ages of 36 and 38 may not extend your healthy life. But if you make small changes consistently every day from ages 36 to 66, that probably will have a big impact. No one diet fits all, and what works for one person may not work for another.
Adopting a diet rich in whole, nutritionally dense foods that can be maintained for life is usually best.