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Sock Doc WorkshopsHere in Part IV of the Sock Doc Essential Guide to Carbohydrates I’m going to discuss the hot topic of a ketogenic diet for athletes. Ketosis is a metabolic state where the liver takes fat and proteins and produces molecules called ketone bodies to use for energy. Ketosis allows a starving person to survive for days (or even months). Some athletes see great improvements in their health and fitness when they’re in a ketogenic state, while others just feel miserable. So is a ketogenic diet right for you?
Ketogenic Diet and Your Brain
Your brain is approximately 2% of your body mass, though it requires approximately 20% of your basal metabolic rate – more if you’re a thinker. That’s not necessarily a joke, believe it or not. Different parts of your brain use different amounts of glucose, and nearly twice as much later in the day than in the morning. If you’re using your brain solving problems and working mentally hard throughout the day, you’ll need to fuel your head more. If you’re working more on motor control, (say a skill involving precision or balance), then you’ll use less glucose. Personally, I can attest to how much my brain uses more energy when mentally challenged. When I’m treating patients in my office, often dealing with complex problems and biochemical pathways, I can’t go as long without eating some carbs than if I was outside training most of the day. Even though I’m using more energy exercising for perhaps six to eight hours, I feel more fatigued when using more of my brainpower for less time.
Though our brains run off glucose and not fat, they can also run off of ketones as an alternative fuel source. Those who promote ketogenic diets tend to note the fact that an increase in ketones improves the recovery and repair of neurons and increases the inhibitory neurotransmitter GABA. (GABA chills you out and helps you sleep. It’s also the main neurotransmitter which sleep medications and anti-anxiety drugs effect.) Due to the effect of ketones on the brain, a ketogenic diet can really help those with epileptic seizures. Of course, ketosis means you’re burning way more fat, (in the form of ketones), for energy than sugar, and for the most part that’s usually good thing.
You won’t venture into a dangerous diabetic ketosis level as long as you’re producing even just a little amount of insulin. So as long as you’re not a Type 1 or pancreas-about-to-fail Type 2 diabetic, there is nothing to worry about. But to stay in a keto-adaption state, you typically need to eat less than 50 grams of carbs per day if not much less than that; it’s not an easy feat. In this state, the body relies on fat rather than glycogen, and the brain relies on ketones rather than glucose.
People wishing to achieve ketosis also can’t consume too much protein. This usually means no more than 150g a day. Protein can be converted to glycogen and as you learned earlier in Part I, this protein can also be used to make glucose and that would throw you out of ketosis.
Ketones Vs. Glucose: Know When To Say When
So should you try to achieve this ketogenic state? Personally I think it’s unnecessary for most, but for some people they need to do it at least temporarily to get their body out of insulin resistance. Again, like most things – it’s very individualized. If you’re severely insulin resistant then this might be your way out of it and on the road to health again. Overall, most people could do better, (meaning become more fit and more healthy), eating less carbs. But I think some people tend to go to the extreme and fear carbs when they don’t need to. Most people also fear insulin since everything we read today about obesity, cancer, and pretty much any disease talks about inflammation and insulin. But don’t forget it’s all about making just the right amount. Insulin isn’t a bad guy, just too much of it is. If you don’t make insulin when you should be you’re actually in a more dire situation than making too much and becoming insulin resistant.
It typically takes two to three weeks to really shift your body over to fat from using sugar as a primary fuel source, and this is with a very low carb, high fat diet. Often just tweaking your diet a little bit won’t do the job to make the shift. You have to go to the more extreme for a few weeks, and then you can add in some carbs after that and see how you react to them, mentally and physically. The nice thing about shifting your body from sugar burning to fat burning is that you also won’t convert back to being a sugar-burner if you eat too many carbs for a short period of time. I put many of my patients on a carbohydrate elimination diet to get them headed in the right direction.
Whether your want to be in ketosis or not is up to you, but you should be able to go days without any carbs (other than veggies) in your diet. Complex carbs should typically only be consumed when you’re training hard or long, or when you just want to eat them because you want something like pizza, a dessert, or whatever you’re into.
Remember, even if you’re only eating around 2,000 calories a day then 100g of carbs is only 20% of your diet. Hopefully you’re getting the same amount of protein and that leaves the fat around 60%, which is around 130-135 grams of fat. (Fat is 9 calories per gram; protein and carbs are each 4 cals.) If you’re training hard, you’ll want some more carbs. No actually you’ll need some carbs. If you’re trying to go on a ketogenic diet then good luck training hard or at any moderate to high intensity for a prolonged period. You will feel like hell, and you won’t last very long. So if you’re going to try such a diet do it in the off season when you’re building a solid aerobic base or when you’re in a recovery period from training hard or racing.
On a clinical note, I’ve never seen a patient do well staying in ketosis for more than a month or six weeks, max. I recently saw a young thirty-year old athlete who has been in ketosis (verifying via blood testing daily) for three months. His pain and health ailments were a result of being in a ketogenic state for so long. The diet initially helped him progress physically and mentally, but it eventually turned on him, without him knowing. He needed some sugars/carbohydrates, and some insulin in his body – less is not always better. I see this same situation every time someone tries to stay on a strict ketogenic diet with no reprieve for weeks, and then months. So if you’re going to go keto, take a break every couple weeks or so, and see how you feel and function in and out of ketosis.
Dr. Stephen Gangemi "Sock Doc"
I'm a board-certified chiropractic physician and clinical nutritionist with a passion for true natural health care. I implement dietary & nutritional therapies, exercise & movement practices, and lifestyle changes along with manual therapy techniques to help the body heal and prevent illness and injuries.
Meghan says
Basically N=1 😉 Any special considerations for females? Like Intermittent Fasting is not suppose to be healthy for most females……
Sock Doc says
Not that I know of. Why do you say IF is not supposed to be healthy for women?
Meghan says
Stepani Ruper @ Paleo For Women wrote this well researched article that has been sited by a few of the big wigs in Paleo like Robb Wolfe, Chris Masterjohn, Diane Sanfillipo Abel James etc….
http://www.paleoforwomen.com/shattering-the-myth-of-fasting-for-women-a-review-of-female-specific-responses-to-fasting-in-the-literature/
Dave Asprey- Bulletproof Executive… I think you drink the bullet proof coffee….
http://www.bulletproofexec.com/a-bad-combination-for-women-intermittent-fasting-and-paleo/
Doctors like Julia Ross have talked about it’s effects on thyroid for women….
Sock Doc says
Actually I don’t drink that coffee (or any coffee more than 1X a month for that matter).
I guess my confusion to your question is that you’re taking about IF here and I’m talking about ketosis. Really not the same, though they may provide some similar results. But they’re different.
I can see how IF (and a Keto Diet) could cause hormonal problems and other issues in women. I don’t have enough clinical experience to comment and I don’t think it’s right to just make comments off “reading the studies” that are out there – they don’t always correlate with what is seen. I would say though that guys have a lot of hormonal problems too, they (we) just don’t see it as obviously as women for, well, obvious reasons. I would caution a woman to try IF or a Keto Diet as much as I would caution her not too – depends on each individual, their current health, goals, etc.
Jaanus says
Hi! What is your opinion on this for diabetics (I am type I)? I have been on no-carb diet for three months in the past and of course I felt great after the initial transformation process (no insulin shots, very nice glucose levels, better overall feeling). How do you feel about such “diets” (it actually could/should become a lifestyle, not a diet) for actual diabetics? I quit because it is mentally very hard to get the right level of vegetables eaten every day, especially during winter, but have played with the thought again.
Sock Doc says
Well if you’re Type 1 and you don’t need insulin shots then you’re doing something special so you should probably just keep doing what you’re doing. Overall diabetics should be consuming less carbs – obviously insulin resistance is what causes TYPE II and now they’re calling TYPE III a type of Alzheimer’s-Insulin Problem.
Vlad says
This is the best summary of the topic that I’ve read to date. Excellent post Doc.
Craig says
Really enjoying this series. I’ve lowered my carbs and increased my fat as per the earlier article and my MAF test has improved quite noticeably. Since increasing my fat intake I’ve noticed that my perspiration smells more after my daily run. Any thoughts on whether changing the hybrid mix to run off more fat and less sugar could/would result in a change in perspiration odour?
Thanks, Craig
PS, where you say people wishing to achieve ketosis also can’t consume too much protein. Should that be “can” consume too much protein?
Sock Doc says
This is from the ammonia forming from nitrogen breakdown from protein. I actually wrote about this (the entire carb series is eight posts long, but I’m not posting any more – you’ll have to wait for the book, sorry). You can either eat more carbs or better yet don’t train to the point where you rely on carbs which your body is providing from protein breakdown.
Guess I should say they “shouldn’t” or else it’ll throw them out of ketosis.
Jacob Golden says
Hi,
This sounds very much like the ‘Two Week Test’ that you and others talk about and that I’m currently doing. Is the process of going ketogenic different then the ‘two week test’? Also, the way I found out about the ketogenic athlete is through an ultra runner named Mike Morton who just placed third in the Western States 100 mile race. He writes about it on his blog. It showed me that you don’t need to be on a carb heavy diet to be a long distance runner.
thanks and great site.
Sock Doc says
This is why I mention the TWT in the article. No, it is not the same. The TWT is just that – a test and you can’t have any carbs on the test other than veges.
Meghan Kennihan says
What veggies can you eat during the two week test? does 30g of carbs from sweet potato count? What about 6grams from cottage cheese……? How strict is this suppose to be?
Sock Doc says
Check out the DRG site where this is discussed in detail.
Meghan Kennihan says
DRG Website? Can you link? or say what DRG stands for… I’m an early bird maybe my brain is just not turned on right now and I should know that abbreviation…
Sock Doc says
Drgangemi.com 🙂
Eric says
The statement below in my opinion is false. I run triathlons and have been on an ketogenic diet for two years.
“Remember, even if you’re only eating around 2,000 calories a day then 100g of carbs is only 20% of your diet. Hopefully you’re getting the same amount of protein and that leaves the fat around 60%, which is around 130-135 grams of fat. (Fat is 9 calories per gram; protein and carbs are each 4 cals.) If you’re training hard, you’ll want some more carbs. No actually you’ll need some carbs. If you’re trying to go on a ketogenic diet then good luck training hard or at any moderate to high intensity for a prolonged period. You will feel like hell, and you won’t last very long. So if you’re going to try such a diet do it in the off season when you’re building a solid aerobic base or when you’re in a recovery period from training hard or racing”
I’m just curious where you based this statement from. Also, 100 g of carbs (sugar) a day is a lot and in my opinion is why this country is so obese. I also had the impression that you were and M.D., but you’re actually a chiropractor. What qualifies you to give dietary advice?
Sock Doc says
Since I hear the insult at the end here – let me ask you this: “What gives a MD qualifications to give dietary advice?”.
Next I would be interested in how you train anaerobically and not replenish glycogen stores. But I’m really more interested in your glorification on the medical society.
Wolfgang says
Dear Dr. Gangemi,
Reading comments like the one of this guy called “Eric” really makes me sick ! Well, guess for every 100 people that you helped improve their health and live there got to be one foul apple as well. Can´t wait for your book, I will put it right next to Dr. Maffetones !
Yours sincerly
Wolfgang (an ultrarunner and HUUUUUUUUGE fan from Austria)
Sock Doc says
Thanks Wolfgang. I don’t bother too much with such bozos. I’m going to hunker down on the book this fall/winter for a spring release.
Michelle Berger says
I disagree with your last paragraph. I train all the time in a ketogenic state and feel much better than when I run on glucose. I am a fitness professional and have even trained on a ketogenic diet for 800m races. My lactic acid build up is not as painful when I am on a Ketogenic diet. Thanks,
Michelle Berger
Sock Doc says
I’d agree with shorter distances such as 800m but not longer events (5K and higher primarily) that tax the anaerobic system.
leosmith says
I realize this is old, but had the urge to respond.
Although I wouldn’t advise switching to ketosis just to try to improve one’s performance, I think we adapt to ketosis and perform just about as well on fat as we do on carbs. So if you “feel like hell”, could it be because you hadn’t fully adapted yet? What were your blood ketone readings? I think it takes a couple weeks of being in the 1.5-3.0 range to start feeling decent in distance events. Of course, I’m just another n=1. But I like the write up in Peter Attia’s blog if you’re interested.
Sock Doc says
Nothing is old on this site! 🙂
And I agree with you. The worse one feels with less or no carbs, the more their body has been using carbs (inefficiently) for fuel. But realize that a keto-diet is much like a “starvation diet” and puts many people in a fight-or-flight sympathetic state, especially if they’re in it too long. So realize that this can negatively affect your health and well being over time.
George says
Thoughts on supplementing with exogenous ketones?
Dr. Stephen Gangemi "Sock Doc" says
I have no experience with them but I think people should be eating really food and if ketosis shows some benefit, doing so without the use of dietary aids.
michael says
very enlightening and trustworthy info…I did go extreme..I went 12 weeks (approx 3 months) with under 25 carbs (only stemming from sauce broccoli). I was feeling alright along the way BUT THEN, all of a sudden, at around the 12th week mark, I felt the WORST ever in life! Short term memory, couldn’t walk up a flight of stairs, couldn’t drive, couldn’t think, gym was hell, was craving things and just an overall ugly situation. I felt like I must put carbs in my body now or else i’m going to kill myself. And so I had a slice of pizza. It was so rewarding and it helped me to feel like a human being again. After conducting some research, and reading over what you blogged about, it seems that strategically adding them, spaced out and in very small doses is the key. It’s funny how you mentioned that you see patients, after prolonged time on keto, feeling like absolute garbage. I train 5-6x/ week and I realize that adding them before and after workout is the ONLY time they’re necessary, if not indispensable (like you’ve alluded to).
Dr. Stephen Gangemi "Sock Doc" says
Thanks for the comment/sharing!
#bestdietrichlife says
Know anything about exogenous ketones?
Dr. Stephen Gangemi "Sock Doc" says
I do and don’t think they should be used to achieve ketosis. Get into that state naturally and with a healthy diet. Many of those ketone supplements are loaded with artificial sweeteners and preservatives too.
Karen Varbalow says
Your advice to go off a ketogenic every few weeks is absurd, as is your statement that you have never seen a patient do well staying in ketosis for more than a month or six weeks, max. First of all, since it takes a few weeks to get into a state of ketosis going off the diet will make your body have to adapt all over again. Perhaps the reason your patients don’t do well after a month or six weeks is probably a function of doing something improper. The data is out there. MANY patients have been in ketosis for years and I know a number who have been in it for over a decade. They all have incredibly good blood work, feel great, and have more energy than before this way of eating. I went on it because of Type 2 Diabetes but as a result a benign brain tumor that I have had for eight years, and which is monitored by CAT scan every year or more, has completely disappeared. Tumors need glucose to survive while your body’s organs can function quite well on ketones. This diet is a life saver for diabetics but I also know many people who have adopted this way of eating for general health and fitness and swear by it. We do not falter because the results are so powerful.
Dr. Stephen Gangemi "Sock Doc" says
Actually I say it’s very individualized and you should try going out of a keto state every so often to see how you feel and I specifically mention diabetics. Obviously if you’re worse then it’s not for you. And saying that my statement that I’ve never seen someone do well in ketosis after six week is also absurd, is the absurd part. You’re basically telling me that those coming into my office after 6+ weeks in ketosis are doing just fine. I didn’t realize you were evaluating and assessing them too.
Roman says
I know people who are in ketosis for years, and feel great. Are they making a mistake? Or is keto a if it’s not broken – don’t fix it lifestyle?
As in, as long as you’re feeling well, you can keto on. But if mental/physical weakness arise, more carbs should be considered?