The Ketogenic Diet: What You Need to Know

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Dietary Fat
There is hardly a day that passes without seeing a new article popping up about the damage sugar and refined carbs can cause but only lately is the connection of sugar to obesity and metabolic disorders starting to be realized. Many people we know may have some weight problems or metabolic health conditions and follow some weight loss program—none of which seems to be effective in the long run. This makes sense. If any weight loss program had led to permanent weight loss, those using it could stop and the company promoting it would go out of business. Long-term (often life-long) membership is essential if one wants to avoid yoyo dieting.

Lately, I see many people rushing to change from the Standard American Diet (SAD) to various new diets, such as the Low Carbs High Fat (LCHF) or the Ketogenic diets. Are all these “diets” for weight loss? Some people call these “fad” diets, but are they?

There was a time when sugar covered cereals were called “fads” but look what has become of that fad! It has become our everyday SAD. Fad is “a practice or interest followed for a time with exaggerated zeal: craze” (here). Sugar covered cereals have been with us for over 100 years, so definitely not a fad. What about the LCHF and the ketogenic Diets? Are they fads? Maybe, maybe not. Let’s dig a little deeper into the ketogenic diet since I consider the LCHF a less strict version of the ketogenic diet.

Is the Ketogenic Diet a Fad?

Looking at its history, “[ketogenic] dietary regimens have been used to treat epilepsy since at least 500 BC” (here). The ketogenic diet utilizes a metabolic process that can be awakened by fasting—though fasting is not necessary. “The ketogenic diet was introduced by modern physicians as a treatment for epilepsy in the 1920s” (here). Therefore, we can safely say it is not a fad. Since it has been used therapeutically for seizures for a very long time, it is not a diet either. What it this ketogenic “thing”?

Ketogenic Metabolic Process

Ketogenic is the human native metabolic process. It is a different metabolic process from the process SAD requires. The ketogenic diet is mostly fat, limited amount of protein, and very small amounts of carbohydrates—the exact opposite of SAD. Eating carbohydrates or protein require insulin for conversion to glucose. Fat is the only macro-nutrient that doesn’t need insulin to generate ATP (Adenosine triphosphate)–in ketosis the role of insulin is fat regulation rather than glucose management to generate ATP (here). ATP is cellular energy, which, after all, is the goal of eating macro-nutrients.

Metabolic Processes

Image from Ketopia.

As you can see in the above image, the end-product for all metabolic processes is the same: energy. However, the complexity differs—this metabolism map is simplified. Note something very important: we can completely remove carbohydrates from the above diagram and not miss a beat in our energy creation. Protein only partially needs to be converted to glucose at the pyruvate step but some protein can directly turn into energy without conversion to glucose. We can remove all sugar, pasta, pizza, cereal, whole wheat bread, all fruits and vegetables from our diet and eat fat and protein instead to meet all our energy need. Most minerals and vitamins are found in meat and dairy so supplementation or eating fruits and veggies may not be necessary. Vitamin C is found in eggs and organ meats.

Why is Ketogenic Important?

Carbohydrates joined our evolutionary path several times, depending on how far you wish to go back. I choose to go back to just before farming. Prior to farming, carbohydrates were hard to come by, especially during the Ice Age. Even civilizations in hot parts of the world, such as the Masai in Africa, don’t eat carbohydrates because they have too little nutritional value. They eat meat, fat, milk, and blood—all high fat and nutrient-dense food. Carbohydrates are not nutrient dense since they lack many amino acids and fatty acids.

The ketogenic metabolic process, on the other hand, is rich in amino and fatty acids, minerals, and vitamins. See the chart below for vitamin and minerals and where we can find most of them.

nutrition in meat

Ketogenic is a simpler metabolic process that burns fat, so the belly you built up over the years can be used up as energy. Furthermore, since our brain is mostly made from fat, we might as well feed it fat. Feeding the brain fat is beneficial to your health in many ways. The ketogenic diet has been used therapeutically because of the high fat. It is used as curative today for epilepsy, cancer, type 2 diabetes, obesity, for neuromuscular diseases like Parkinson’s, Alzheimer’s, MS, sleep disorders and autism, and even migraines and much more. It appears that the ketogenic way of eating cures the negative consequences of the SAD diet.

Is Ketosis a Starvation Diet?

People often label ketosis, the method of fat burning in the ketogenic diet, a “starvation” diet. Some even call it a state of “acid-base disturbance” without realizing its importance. However, ketosis is far from being a state of starvation since our body has a lot more fat-storage ability than glucose (glycogen) storage at any given time. While our liver can retain maximum 500 grams of glucose equivalent in glycogen (about 2000 calories worth of energy), our body contains tens or hundreds of thousands of fat calories (depending on how much fat you carry). Should a famine ever arrive, the ones starving to death will be those who depend on the availability of carbohydrates and not those who can store and burn their fat.

We need to turn the “starvation” theory up-side-down. Carbohydrates (prior to our commercialization) were only available for short periods of time and only in some places where the climate was favorable. How did humans survive in cold climates or seasons? Eating fat and meat – of course – from the animals they captured.

How Can More Calories be Generated by Starvation?

From each gram of fat 9 calories of energy are generated, whereas from a gram of carbohydrates only 4 calories of energy is generated Which one is the starvation mode in your opinion? It seems that consuming carbohydrates makes sense only as a desperation move in times of fat shortages.

Note that if you eat only carbohydrates, you need to eat 2.25 times as much as when you eat fat since carbs only generate 4 Calories whereas fat 9 (simple math). I would think that a starvation diet becomes necessary when nothing better is available. In this case, carbohydrates offer less than half the energy so that is indeed the starvation diet. Furthermore, the length of time one needs to eat also matters. Surviving on carbohydrates takes 2.25 times as long eating-time as surviving on fat if we want to eat the same amount in calories. This translates very well to our modern society where eating three main meals and two snacks is necessary to survive on a carbohydrate rich SAD diet while those on the ketogenic diet may eat only once a day to get the same calories (this is because of the calorie differences macro-nutrient types provide). Since the ketogenic diet is so much more advantageous, let’s evaluate some common beliefs about it.

Keto Flu

Keto flu is not an illness. It represents a transition time for your body from carbohydrate to fat burning mode. It requires the cooperation of many hormones and the replacement of some cells since these metabolic processes are extremely different. During this initial period you don’t burn fat efficiently, you may feel more tired during workout, have a headache, cramps, or bad breath. This period may last anywhere from a couple of days to several months. It does dissipate, however, but most academic research has been conducted for too short a time period for the keto flu to pass and much fight is ongoing to prove that. The subject is still only discussed within academic circles.

Individuals who try the ketogenic diet have little support from their doctors and nutritionists, most of whom have never heard of the ketogenic diet because they must follow the dietary guidelines of the USDA or the American Heart Association. As a result, people must rely on the often inaccurate ketogenic material found on the Internet, as this dieter explains.

Useful Ketogenic Information

Ketogenic diet is inhospitable to most parasitic and bacterial life in the human body (here). Bacterial infections, yeast and perhaps even mold find it impossible to survive in an environment that uses fat rather than glucose for metabolism (here). Cancer is a metabolic disease that feeds on glucose (here). Where there is no glucose (or a very limited amount), there is a much smaller likelihood of cancer–cancer is a metabolic disease (here).

My Experiences with Dairy

Whole milk doesn’t affect ketosis . Whole milk has no sugar (in spite of the label on the box). It has lactose. Lactose is a disaccharide, meaning two molecules are bonded: glucose and galactose. Lactose requires the enzyme lactase to break it up and this happens in the intestines. Therefore, the sugar from milk doesn’t increase in the blood until the enzymes have broken lactose into glucose and galactose (here). Since lactose is a disaccharide bond between glucose and galactose, only 50% of it is glucose. While glucose certainly finds its way back to the blood from the intestines, it does so slowly and perhaps some happy bacteria already fermented some of it. So, even the assumption of 50% returning as glucose is very generous.

Lactose free milk affects your glucose levels immediately because in this type of milk the lactose is already broken up into the simple sugars of glucose and galactose (here). Don’t drink lactose free milk in ketosis.

Yogurt interferes with ketosis because of the fermenting of lactose by the bacterial cultures produce lactic acid (here). This means that much of the lactose bonds have been broken before you put yogurt into your mouth. Yogurt will likely bring you out of ketosis—depending on how much glucose is left unfermented in it.

Medicines, Supplements, and Ketosis

Prescription medicines as well as some supplements may interfere with ketosis (here). This is rarely if ever talked about but I can pass on my experience. Many medicines and supplements use insulin receptors to get into our cells. A notorious prescription medicine to instantly bring you out of ketosis is Prednisone—including corticosteroid epidurals. Prednisone uses up all the insulin your body is capable to produce (it can induce type 2 diabetes) and starve the brain of glucose (some brain parts always need glucose though small amounts). The more the brain demands glucose, the more glycogen the liver pumps into the blood but as there are no free insulin receptors, blood sugar levels may reach near diabetic level (mine did from Prednisone).

Some vitamins, such as vitamins D and C also use insulin receptors and you may find similar behavior to Prednisone (here). Some medicines may work against ketosis. The ketogenic diet works best in a medicine free body because this “diet and nutritional supplements improve so many conditions that the prescriptions often become an overdose or unnecessarily strong” (here). Furthermore, Western Medicines are made to work in a carbs-burning metabolic process so it is not at all surprising that they don’t work in a fat burning metabolism.

For example, some seizure or heart arrhythmia medications may become agonists in a ketogenic metabolic process. Ketosis is a state when your body is in recovery mode, rebuilding fat and cholesterol in your brain and heart to insulate your voltage passing neurons. Medicines that block these neurons from working, such as voltage gated calcium channel blockers or voltage gated sodium-potassium pumps or channels blockers, may end up amplifying the  condition by working against the medicine while the medicine is working against the ketogenic repair process—this happened to me.

A person should not come in and out of ketosis. One is either in the ketogenic metabolic mode or out. A body can only have one metabolic process at a time given that both processes use insulin but for very different purpose–as described earlier. When a body is not used to eating carbohydrates, the insulin resets to a healthy level. This means that the reaction to a cheat day may bring with it a diabetic level insulin spike. Repeat this often and this may become a factor in insulin resistance that perhaps nothing can reverse. So make a decision and stick with it. As my body proved it to me (and to a few others in the ketogenic mild for migraine group on Facebook), once the body is in efficient fat-burning mode, it wants to stay there.

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27 Comments

  1. I was prescribed Methylprednisolone for fluid in my ears (that was causing extreme dizziness) at around the 30 day mark of being on the Ketogenic diet. It caused extreme heart palpitations and knocked me completely out of Ketosis (after I had finally reached “large” ketones through elimination of caffine). I stepped down the medication due to the palpitations.

    While trying to figure out how long this drug is going to remain in my system (we’re reading 8 days for each dose I took?), should I continue eating Keto or go back to a “normal/healthy” non-keto diet? I don’t want to risk causing further damage to my body, certainly not developing diabetes, as I am predisposed for the disease already (familial as well as having PCOS/insulin resistance and hypothryroid).

    1. Dear Kat,

      Very sorry to hear what happened to you–this happened to me as well. The half-life of Methylprednisolone is up to 36 hours, but then there is half of the half and so forth, s the total elimination of one dose is about 72 hours for your last dose and by then the previous doses would all have been also been reduced to close to zero. However, drug out of the system doesn’t mean full recovery, since it causes all kinds of damage that also needs to be reset.

      Prednisone interacts with ketosis quite strongly. Most doctors don’t know what interacts with ketosis since there is no written information and no clinical trials. The only drug so far that the FDA placed a black box warning on with ketosis is Topamax.

      My experience is broader than the FDA acknowledges. Ketosis interacts with all medications that cross the blood brain barrier–the few that don’t are rare (benzodiazepines don’t for some odd reason) and so my assumption is always: ALL DRUGS INTERACT except for thyroid and birth control medicines. Even they do to some extent, like most people on thyroid medicines will have to lower their dose because the thyroid tends to recover in ketosis.

      Back to your condition: not sure I understood what you meant by “after I had finally reached ‘large’ ketones through elimination of caffeine”… what is meant by large ketones? How are you measuring it? (Blood, urine, breath?) And if caffeine caused trouble with ketosis, you can already see that there is a connection between ketosis and coffee in your case. I find that coffee initiates an insulin response in the population of people I work with (migraine sufferers) and that this is associated with metabolic disease to some degree. Migraineurs have what I call “reactive insulin response”, meaning that fasting insulin will give normal results but an OGTT (oral glucose tolerance test) will not. Their insulin will spike sky high. For this reason, for this population, coffee breaks the fast.

      Otherwise, the “large” ketone numbers concern me. Many books make people believe that “larger is better” but that’s not true. Once in ketosis, you are in ketosis. The deeper (larger ketones) you have, the more your body depends on ketones for fuel–consider this like a paper-towel placed into a spill. The greater the spill, the larger area of the paper-towel will be wet, but the wetness itself doesn’t change. What changes is how many mitochondria within your organs switch to ketosis and how fast, and whether you burn only fat or also protein–meaning your own muscles. I am not fond of large ketones at all. It is not necessary. What is necessary is that you are in ketosis all the time and that your body is an efficient ketone burner.

      I am in the process of writing a book on this because there is so much misinformation out there. You are welcome to join my keto group here. Originally it was only for migraineurs but by now a lot of people have joined without migraine as well.

      In terms of returning to ketosis: absolutely I would. I would not ever go back to SAD! Not if they paid me for it. There is a great reason for you to be concerned so stick with ketosis and look into nutrient deficiencies. Heart palpitations, in particular, can be caused by you not consuming enough salt on the ketogenic diet, not drinking enough water, not taking enough magnesium, or B1. So check all variables–ketosis is only a magic bullet if it is applied correctly.

      Best wishes,
      Angela

  2. I am taking Exemestane (Aromisin) to stop the production of estrogen since I have had breast cancer three times. Is it safe to be on the Keto diet and take Keto pills.

    1. Dear Jean,

      I read through the pharmacology of Exemestane, which is a form of steroid that blocks estrogen receptors from acting as such. There is no literature on medicines–other than Topamax–for the time being against ketosis and the use of the drug at the same time. It is always a trial and error it seems with most medicines as a result. From the perspective of pharmacology, I see no cause for concern, provided you actually can get into ketosis, given that Exemestane is a steroid.

      I recommend that you discuss with your doctor, in case there is some medical opinion on this that is not yet published.

      As far as I know, breast cancer is a type of cancer that responds very well to ketosis. The important part of ketosis against cancer is the lack of glucose rather than the increase in ketones. Most cancers are glucose-loving, so the idea is to reduce glucose in your blood to the minimum that is sustainable for your health, at which point your body will automatically switch over to burning ketones as your fuel for those organs that can use ketones–that is most organs but not all. Those that cannot use ketones–such as your red blood cells–will continue to use glucose, which is made by your liver from proteins and stored fats–triglycerides.

      Therefore, rather than taking ketone supplement–and depending on those ketones to create a miracle–if you decide to try ketosis, do so by changing the way you eat, rather than popping pills. What the best way of eating is, is individual. However, knowing what cancer cells like to proliferate, it is clear that the least amount of carbohydrates in your diet, the better.

      If I had breast cancer, I would get on the carnivore diet with absolutely zero carbs in my diet: only meat, seafood, organs, and animal fats.

      Best wishes to you,
      Angela

  3. I am on prednisone for pulmonary sarcoid right now. Should I stop following my keto plan until I’ve stopped taking it?

    1. Dear Angela,

      Prednisone will actually kick you out of ketosis because it forces your body to release massive amounts of glycogen for glucose, and you insulin will also increase. You can continue with your keto diet only you won’t be in ketosis. Once you stopped the drug, you will automatically balance out again in ketosis. I would recommend you stay on the ketogenic diet. With all that glycogen being released for no reason, it is best to reduce the exogenous glucose as much as possible. 🙂

      Good luck,
      Angela

  4. Hello Dr. Stanton!

    I have psoriatic arthritis and take a very low dose of prednisone. I’ve been taking 5mg daily since 2013. I’m also taking Celebrex and injecting Enbrel. I’m just starting the Keto diet and wondering if I can effectively and safely lose weight while on prednisone.

    Thanks in advance.
    Patrick

    1. Dear Patrick,

      You can certainly start the ketogenic diet but may find it very hard to get into ketosis. However, it is worthy to try, since to start the keto diet means you will be quitting those foods that caused your psoriatic arthritis the first place, namely grains and possibly dairy and egg whites. As you quit those foods and start a healthy eating that is grain-free (not gluten but all grains), sweetener free. I recommend you also quit naturals and substitutes since they are known to predispose or start insulin resistance on your way to type 2 diabetes, which is something Prednisone is already doing. Please be sure to study up on a healthy ketogenic diet that is not full of fat bombs and butter in your coffee. That kind of ketogenic diet is unhealthy. You need to be sure you consume a nutrition-rich diet full of fats that are “attached tot he animal” for its full nutrition. Quit all vegetable and seed oils and enjoy fruit oils like avocado oil, olive oil, and coconut oil, in addition to animal fats–such as bacon dripping that you create.

      Good luck on your new diet and pay attention: likely you will be able to taper off all your medications and eventually quit them. The keto diet has amazing healing power for humans and most diseases that are autoimmune–meaning they were caused by diet and environment–revers.

      Best wishes and good luck!
      Angela

  5. I have been on Keto diet for 2.5 months, for both weight loss and to combat Meniere’s Disease. I recently had some significant dental work & now my teeth are incredibly sensitive & painful. My dentist prescribed a Medrol dose pack but i have been afraid to take it because I don’t want to gain weight or retain fluid. Fluid retention is what makes Meniere’s symptoms flair. The pain is getting worse & I am thinking of just taking the Medrol. Is that as bad as prednisone?

    1. Dear Maggie,

      Sorry for the delayed response–summer vacation and other issues. I hope my answer will still be useful for you. If you are on the keto diet and start taking Prednisone (Medrol dose pack is Prednisone), you will be kicked out of ketosis while taking it.

      I am not sure if you ended up taking it or not. In general, for fluid retention you can take a diuretic if it is that much, or increase potassium in your diet–that too will remove lots of fluids. If it is edema in a place where you can see it, such as ankles or puffy eyes, taking some salt without water also works very well–this is what I do for an occasional edema.

      I hope your problem is resolved by now with no serious issues.

      Best wishes,
      Angela

  6. Due to sudden onset nephrotic syndrome, my kid is on high dose prednisone. I was told of a myriad of mental symptoms. I immediately thought Alzheimer’s. I shan’t bore you with what they fed her in the hospital. Then, what I was told. Her Nephrologist sent me to nephcure whede I should feed her healthy canola sunflower oils. Coconut and olive are ok too. But, don’t give her dairy and animal fat due to its high saturated fat. Egg whites but not egg yolks (whereupon protein, potassium, phosphorus issues as compared to healthy vegs, use spinach with its glass cutting oxalates, are ok)

    feed her fruit… exactly what is happening when all that fructose is free flowing through the blood when the liver is in a round of gluconeogenesis? not to mention all that glucose from those high fiber, healthy, whole grains and the skim milk recommendations?

    Obviously, I could go on for hours about the advice I am being given. You know my complaints all too well.

    I did figure out, mct, chain 8 heavy, powder stopped that ravenous prednisone induced hunger. Your explanation about blocked glucose uptake, makes sense.

    And, the advice to take pred in the Morning, this disrupting all 3 meals, seemed off. So she can sleep. Again, The sleep disruption sounded more like brain hunger. guess what a doss of mct dose for her? So, I give her medicine midafternoon, she then runs around adter school with the kids when the glucose being cranked out is in high gear, eats 2 full meals full of essential fatty acids, and mct brain food when I sense her getting confused. I haven’t heard, I am hungry, outside of normal mealtimes in 3 days.

    1. Dear Polly,

      Oh my what “foods” she has been given… I think “healthy” and “canola sunflower oils” is an oxymoron… if you can please avoid those. MCTs are great–be sure you only get it from coconut oil and not palm kernel oils. Palm kernel oil, other than devastating the planet, can also cause gastric distress, so best stick with real food, such as coconut oil. Nephrotic syndrome is the inability to digest protein well. Has she had a blood test for carnitine?

      Unfortunately Prednisone leads to metabolic syndrome and also life-long treatment with steroids. How long is she going to be on that? Her hunger is likely a sugar crash. You may want to check her blood glucose if she doesn’t object to being pricked on a finger. It is definitely induced by Prednisone.

      I would most certainly provide a completely different diet for her. But you know that, don’t you. 🙁 It is really hard to find a doctor who is completely up to date and knowledgeable.

      Many hugs to you and your daughter!

      Angela

  7. So glad I came across your site! Wondering your thoughts on a keto/ hormone related issue I’ve had. I love the keto lifestyle, and was in ketosis for about 2.5 months. During that time, I had a very heavy, unusual 6 week period, which was ultimately only stopped by hormonal intervention. (Big doses of birth control pills). A follow up ultrasound showed a uterine polyp, which the OBGYN considered the cause of this crazy period.

    I was/ am curious about the interaction of ketosis on my hormones. I know that polyp growth can be stimulated by estrogen. In addition, I have heard that since estrogen is stored in fat, the fat metabolism in ketosis can cause a surge in estrogen. This makes me think that my ketogenic diet led to the growth of the polyp, and the resulting abnormal menses.

    As much as I loved eating keto, I really hated that period. I’ve stopped eating keto, and haven’t had a recurrent period like that.

    My questions are: Is the connection I’m making off base? If there is a connection, is there some kind of moderated ketogenic diet that would give me the benefits without this kind of hormonal side effect?

    1. Hi Heidi,

      Great question. I so far have not seen or heard, what is happening to you, from others–this doesn’t mean it is not happening or that the connection is not there, only that it is not likely to be common. The only relationship of fat and estrogen that I could find in a rush is here. It is a hard thing to search for because a lot irrelevant articles pop up for estrogen and adipose (or fat) tissue… most have something to do with weight loss or gain rather than what you experienced.

      It is well understood that ketosis changes fertility and many women also tend to cycle out of ketosis during their PMS and part of the period itself. Those definitely are hormonal but more progesterone related. Progesterone uses insulin and glucose backs up. So PMS time both glucose and insulin increase in the blood, inhibiting ketosis and fat loss. Ketosis also tends to set fertility to a higher level in women–it seems to provide more nutrition, vitamins, and minerals, in spite of not supplementing any and perhaps more estrogen–research is lacking. Meat has more nutrition than greens and has no antinutrients. So I see more women getting pregnant easier but usually ketosis stabilizes the period.

      The only alternate diet that is still ketosis but to a lesser degree is the carnivore. I find that most people start with keto and migrate toward carnivore and stay there. This happened to me as well. It is better for many people–perhaps not all. You may want to give it a try. Carnivore is only animal/seafood products, including organ meats (like liver) and dairy. It is a very satisfying nutrition plan. 🙂

      Try it and see how that works. Keep us posted! 🙂

      Best wishes,
      Angela

      1. Hi, years ago I had the same problem, and my gynecologist wanted me to have a complete hysterectomy, so i consulted another dr. and she recommended motrin 600
        at the beginning of the period, To thin the lining of the uterus and stop the period.
        It work for me.

  8. Have been ketoing very successfully 6 months, primarily for weight loss. Not T2D. . Indication that I am keto-adapted is that urine testing has gone from early 1.5 to negative. (Breath or blood testing not avail to me.)

    Today I started a tapered course of prednisone for bronchial problem. Assuming that I will go out of ketosis, I’m wondering if I should increase carbs temporarily. Ilimit carbs to 20g.

    I am very pleased to find your website for my daughter, who is plagued with migraine. All meds and even surgeries have not offered relief hoped for.

    Thank you.

  9. 1. Are You saying that it isn’t even worth trying keto on prednisone? 60mg/day… i know that’s a lot but i still feel as if ihave to try with my only concern being something accidental like ketoacidosis. They’re adding in metformin now.

    There’s a guy by the name of dr eric berg who is on YouTube and has many informative videos on ketosis and intermittent fasting. A few touch on prednisone use. Could you please take a look and let us know what you think?

    Thanks
    Eric

    1. Hi Eric,

      I am familiar with Dr. Eric Berg though I have not watched all his videos and I have not watched any in which he discusses prednisone. So my take on it is based on my readings and experience with my migraine sufferers who are prescribed prednisone, and my own experience when I was prescribed it once.

      There is a significant body of academic literature behind how prednisone–and steroids in general–induce/cause type 2 diabetes. See here and here and here just a few of these. The important factor is how corticosteroids work and how that induces such a drastic change in metabolic processes that induce/cause T2D. Once you understand the physiology behind that, you will understand why it causes T2D and thus you will understand why it is not possible to stay in ketosis while takign prednisone, a corticosteroid.

      Steroids block the liver from being sensitive to insulin, e.g. cause insulin resistance in the liver and the liver keeps on pumping out glycogen l. Even the Dawn Phenomenon is part of this for most people, an increase in blood glucose as a result of the release of the steroid hormones that awake your body, organs, and mind but cause a mild insulin resistance in the process. This is a natural process. Temporary insulin resistance, even seasonal insulin resistance, is not a problem. Insulin is an anabolic hormone that is used for energy storage, and to do that, it needs a temporary insulin resistance. All is well with that.

      Taking prednisone as a medicine though is the introduction of artificial steroids ==> introduction of artificial insulin resistance ==> if going on for a long time it leads to chronic insulin resistance. Chronic insulin resistance is T2D at a certain intensity. The most typical thing about insulin resistance is that it means “increased insulin” in your blood. Now put that together with ketosis, which comes about when your blood is low in insulin. It is awakened by glucagon, the anti-insulin. So on the one hand you have high insulin levels and on the other hand you need to have low insulin levels to be in ketosis. So you can see the conflict in this statement. Thus simply stated: takign prednisone and being in ketosis is mathematically impossible. However…

      There is always a “however” in everything…

      Being in ketosis is not the same thing as making ketones. can you make ketones while taking prednisone? Absolutely! How? Easy actually. When you have insulin resistance–for whatever reason–one of the key background events in your body is that your cells have no access to enough glucose for energy. With not enough energy from glucose, your body will get into starvation mode as a result of hormonal signaling. Starvation signal overrides other signals and your liver will release ketone bodies and also additional glycogen for glucose. As your glucose will increase your blood and your insulin will increase with it–the pancreas is in communication with your organs and will release more insulin for the additional glucose your liver released as glycogen, glucagon send the ketone-production signal to the liver.

      So now you have high glucose, high insulin, and also high ketones. Great. Ketones are the backup fuel when glucose is present, so your body/brain will use minimal ketones while too much glucose is in your blood. Too much glucose is toxic so the body does its best to get it out of there. So ketones will not be burning as your body is trying to burn the glucose. While this is happening, you may find (assuming you measure blood glucose and also blood ketones–beta hydroxybutyrate) very high blood glucose and blood ketone levels fr some time and then a sugar crash–hypoglycemia–as insulin is finally allowed to become sensitive again and it all of a sudden takes all extra glucose out of your blood and then some. By the time this happens, there is little time of the day left if you only take your prednisone once. If you take it twice, there is no time left since now you are taking your next pill and the cycle repeats.

      So as you can see, it is impossible to “be in ketosis” while taking prednisone, though you certainly will have ketones in your blood. And, by the way, increased insulin prevents ketoacidosis. Ketoacidosis is when you have high glucose and high ketones, and no insulin. That cannot happen while on Prednisone, unless you are on it for many years.

      Now about Metformin. Metformin take glucose out of the blood by reducing liver gluconeogenesis–meaning the amount of glycogen the liver can make. It also blocks some glucose absorption in the digestive tract and makes “insulin more sensitive” (I put this in quotes for a reason). Making insulin more sensitive means it literally forces insulin into a labor-camp and forces it to store glucose as fat. One of my friends who was on Metformin for T2D ended up with triglycerides of over 600 (<145 is normal) as a result of Metformin. How do I know that? She came to me for help and went on the low carbs diet (in this case carnivore, which is zero carbs) and not much happened other than she had some digestive issues. Then she also quit Metformin and within one month, her triglycerides went from over 600 to 167, which is still high but hey, look at the change.

      So it is clear where Metformin does its work: it forces insulin to make the extra glucose into fat–triglycerides–and deposits that into adipose tissues that are in or around organs (ectopic or visceral fats, respectively). So Metformin doesn’t actually help your ketosis either. It makes it worse in terms of your body’s ability to regulate its glucose needs by preventing gluconeogenesis, thereby increasing the potential for a major hypoglycemic event.

      My recommendation: if you want to be on the ketogenic diet, you can be on that regardless whether you will or will not end up in ketosis. The goal is to reduce the onslaught of glucose that is an oversupply to the body. A “diet” is a tool and not a goal. Taking Metformin is “misinformation” for your body. It prevents your body from properly operating your liver and with that, it interferes with ketosis. With Metformin, you may still be able to get into ketosis but at the price of your liver’s inability to regulate to what degree. That can be a problem if glycogen is not released properly and you are not eating enough glucose. Your red blood cells must have glucose–they have no mitochondria–and if Metformin blocks gluconeogenesis and you are not eating glucose, your red blood cells may not get enough glucose for their own survival. That is a risky proposition and I would not recommend it. If you are on Prednisone long term, being on the ketogenic diet, while it may not get you into ketosis, will allow your body to make the glucose it needs for your blood cells and will allow some ketones to be used here and there. You will not be in ketosis but will use some ketones.

      Best of luck,
      Angela

      1. I’m a kidney transplant recipient for 3yrs now. I have to take prednisone 5mg daily. I really don’t have that steroid appetite. I’ve gained so much weight. This past year was the worst. I’m post menopause for two years now.
        I was hopeful in trying intermittent fasting. I’ve rear much research by Dr Jason Young who has helped patients with diabetes. I just can’t find anything on Prednisone and IF.
        He did say it’s not calorie restriction it’s what happens when you fast 14:10 to 16:8 for women.

        What do you know of best way to lose the weight? Is IF not going to work with prednisone?

        Thank you very much.
        Sheila

        1. Dear Sheila,

          Dr. Jason Fung works with patients of type 2 diabetes (T2D) and kidney disease is one consequence of T2D. He advocates various time restricted eating or intermittent fasting and even longer term fasting, but this is not likely appropriate for someone like you who is a kidney transplant recipient. Your body is fighting other elements here not just weight and potential T2D.

          Unfortunately Prednisone works against ketosis and will not allow you to remain in ketosis. I had first-hand experience with that, and there are many studies discussing that corticosteroids actually cause T2D. It increases insulin and since it s caused by medicine, it is not under your control to reduce it. This is likely why you gained so much weight as well: because of Prednisone.

          The point is not actually calorie restriction per se but carbohydrate restriction. And that is because why you may not be eating food, in ketosis your body is able to take the stored fat and use it for calories. So your body is not actually “fasting” or eating less, since it is able to use as fuel whatever it stored specifically for times when there is no food. However, Prednisone is a major stumbling block in that. If you had no kidney transplant and potential hazards as a result, fasting woudl definitely be a good way but with your health condition, this may be harmful for you.

          I recommend you contact Dr. Jason Fung–he is in Toronto. Since I ma not an MD I cannot help you or advise you in any way. And most certainly he woudl be the best person to talk to.

          Best wishes to you,
          Angela

  10. Very insightful! I’ve been on the Keto plan since 2/2018 and have had a very positive benefit on my migraine threshold. I still have migraine attacks, but the intensity and duration have been reduced more dramatically than any pharmaceutical efforts to date(40+yrs). I do however have other neurological pain disorders – primarily occidental neuralgia and fibromyalgia which do not seem to benefit at all from the ketosis. Because of that I often take various meds including prednisone just to get through bad flare ups. I have also noticed your same observation of the negative effects of medication on ketosis but don’t know of any other options. Have you done any research on other pain relief options for nerve pain?? Thanks for sharing!

    1. Thanks Karen. Indeed, keto is limited in how far you can go if you take medicines, particularly if you take prednisone, since that actually kicks you out of keto. I found that no one can stay in ketosis while taking Prednisone.

      However, I have found alternatives that do work very well for fibromyalgia. While fibro and migraine are not the same conditions, there seems to be an overlap since there are many people with both. In addition, the ketogenic diet for those with migraines needs to be slightly different from keto for regular people who apply it for weight loss, or those who use it therapeutically for seizures. I created a specific keto version for migraines that seems to work better for migraineurs. I also have a fibromyalgia group on Facebook and a migraine group. I post here for you all three groups; you are welcome to join all there though if you need to take Prednisone I recommend you don;t go the keto route.

      The migraine protocol group, the fibromyalgia group, and the ketogenic group for migraine.

      Looking forward to seeing you in one or more of these groups,
      Angela

  11. I wish my obese, diabetic sister would read this! Great article! I’ve been on a Keto diet for about 3 weeks now and I’ve never felt better! Just trying to understand if I should continue to take my HRT patch estradiol…not sure if I still need it or not now that I’ve changed my diet to keto! Thanks again for the great detailed explanation about how keto works for our bodies!

    1. Thanks Kimberly for your comment. Indeed, it would be great if you had the chance to share this article with your sister.

      In terms of HRT patch estradiol: in my experience estrogen doesn’t interfere with the ketogenic diet but progesterone does. It makes it harder to get into ketosis and stay in ketosis. In terms of whether to stop it or not, that would be your decision with your doctor–I don’t think the ketogenic diet modifies your sex-hormonal response. Insulin resistance, T2D and similar have much more affect on sex hormones than the ketogenic diet.

      I hope you continue on the ketogenic diet with success!

      Best wishes,
      Angela

  12. This is the best article I’ve read in a long time. Thank you so much for the time and energy you put into it.

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