When I ramble on about the physiology and metabolic mechanisms behind the changes most of us will feel when embarking upon a ketogenic diet pattern, eventually everyone interrupts me with this question: but what do you actually eat?!
That’s a fair question. A ketogenic diet is very difficult for a lot of people to wrap their minds around since they have been told for most (if not all) of their lives that dietary fat will kill them and should be avoided.
For those looking for a quick start with the ketogenic diet, let’s briefly talk about what will and will not fit into a ketogenic diet plan. Later, we’ll discuss these topics in more detail.
Foods That Do Not Fit a Ketogenic Diet Plan
It is easiest to start with the foods that have no place in a ketogenic diet. Here is a quick list of things to be omitted:
grains
legumes
most fruits
starchy vegetables
sugars
Let’s break that down a bit. If you can’t eat any sugars, grains, starchy vegetables, legumes, and most fruits, you also can’t eat many of the following:
baked goods
beans
breads
candies
cow’s and goat’s milk
pastas
potatoes
I realize that upon reading that list, many of you had the urge to throw this book across the room. I accept that and hope we can move past it.
The ketogenic diet and any diet based on it, like the Ketogenic Mediterranean Diet, must be a very-low-carbohydrate diet. There is no way around it. Carbohydrates suppress ketone production. As one who has been eating the ketogenic diet for over a year, believe me, I understand how daunting it sounds to give up all of the sweets and sweetened things in our modern diet. Also believe me when I say it is worth it.
Foods That Will Fit a Ketogenic Diet Plan
The foods that will make up the majority of your diet include non-starchy vegetables, fatty fruits and their oils, nuts and seeds, eggs, dairy excluding milk, fish, and other meats. Non-starchy vegetables include just about all vegetables except potatoes, sweet potatoes, carrots, and corn. Fatty fruits would be avocados, coconuts, and olives. Berries may be included in moderation. Nuts and seeds will be useful but must also be eaten in moderation, as they have a moderate amount of carbohydrate content, depending on the variety. Almost all cheeses and some yogurts can fit nicely within a ketogenic diet plan. Look for Greek yogurt and make sure it is not sweetened, because many commercial yogurt varieties have outrageous amounts of sugar added.
Don’t make assumptions about a food product’s carbohydrate content if you are dealing with anything that has a label. The nature of the industrialized food supply in the United States is, to use a technical term, nutzo. Sugars or corn derivatives are added to just about everything. Here are some examples of processed foods that have more carbohydrates than they rightfully should because of added sweeteners.
beef jerky
dressings
ketchup
peanut butter
processed cheeses
sausages
tomato sauce
yogurt
Using the broad strokes painted above, put together meals such that you do not exceed twenty grams of net carbohydrate daily for at least three weeks, at which time you may be able to increase your daily amount to as much as fifty grams. Your particular carbohydrate tolerance is unique, but for this diet I recommend that it fall within the range of twenty to fifty grams per day.
Net carbohydrate is the term used for the amount of carbohydrate that the body can actually digest. Because we cannot digest fiber, we do not have to count the fiber portion of the carbohydrates we eat toward our daily total. To determine net carbohydrate, subtract the grams of fiber from the total carbohydrates. This method is not universally accepted within the ketogenic community because of variability between how different bodies metabolize fiber. I recommend using the net carbohydrate method, but you should try to give yourself three to five grams of wiggle room per day. See Chapter 10 for specific recipes and Chapter 11 for a meal plan.
Strangely enough, there are a couple of almost-carbohydrates that can fit within a ketogenic diet plan for some people. Sugar alcohols and non-nutritive sweeteners can be useful additions to a ketogenic diet plan because they can be utilized in desserts and drinks if you occasionally crave something sweet. However, as you will read, they should be used sparingly and you will need to experiment with them to find your level of tolerance.
Sugar Alcohols
Sugar alcohols are not sugars at all, but polyols that occur naturally or are derived from sugars through chemical processes. They are used as sweeteners or thickeners and tend to be less sweet than table sugar. The body does not metabolize sugar alcohols very well, but they will provide some calories when eaten. Though they are generally regarded as diabetic and keto safe, they do raise blood glucose levels and inhibit ketone production in some individuals. They also commonly cause bloating or diarrhea if you consume too much. Unfortunately I can’t tell you what “too much” means, because they tend to affect people differently. You’ll just have to experiment and see how you react. You can spot them on labels because they all end with –ol. Some commonly used sugar alcohols are erythritol, glycerol, mannitol, and xylitol.
NON-NUTRITIVE SWEETENERS. These appear in almost anything with the word “diet” on it. They are called non-nutritive because, like sugar alcohols, the body does not completely metabolize them and they don’t provide much in the way of nutrition. None of the non-nutritive sweeteners raise blood glucose levels or interfere with ketone production.
The use and ingestion of non-nutritive sweeteners is a topic that people tend to feel very passionately about. Over the years, there have been anecdotal accounts of these substances being linked with everything from migraines to obesity to cancer. The problem is, there is no quality clinical evidence to back these claims up. I believe that it is best to avoid these in favor of developing a palate that is less accustomed to sweetness, but I do not think that occasionally consuming them will do you any harm. The FDA has approved the use of these sweeteners:
acesulfame-K (Sweet One)
aspartame (NutraSweet and Equal)
neotame
saccharin (Sweet’N Low)
sucralose (Splenda)
stevia (Truvia and PureVia)
What a Ketogenic Diet Is Not
There are a few things that you will undoubtedly encounter repeatedly once you embark on a ketogenic diet pattern. I do not know why these myths surrounding ketogenic diets are so pervasive, but I suspect it has something to do with how different the ketogenic diet is from what people have been told all their lives. Regardless, I want to take a moment to make very clear what the ketogenic diet is not.
KETOACIDOSIS. Typically, this is the first point of confusion that needs to be clarified for friends and family. Ketoacidosis is a potentially deadly condition that insulin-dependent diabetics (type I and advanced type II) are at risk of developing if they do not get enough exogenous insulin. Basically, glucose cannot travel from the bloodstream and into the cells that need it, so the body begins to make ketones as it does when actually deprived of carbohydrates. Danger occurs because insulin is also the hormone used to stop ketone production. In the absence of insulin, ketone production can run unchecked and eventually reach a point in which the pH of the blood is affected by the excessive amount of ketone bodies present. Because ketone bodies are slightly acidic, their accumulation will drive the pH of the blood down, which can very quickly result in coma or death.
In individuals that have functioning insulin-producing and storing beta cells on their pancreas, ketoacidosis will not occur. To borrow an example from Dr. Peter Attia, a medical doctor studying diet and longevity, nutritional ketosis and ketoacidosis are similar in the way that a nice toasty fire in a fireplace and an uncontrolled house fire are similar. They are both fire and both provide heat energy, but one is safe, beneficial, and contained, while the other is out of control and potentially deadly.
A STEAK AND BACON DIET. Honestly, of all of the misconceptions about a ketogenic diet, this one bothers me the most. As a former vegan who understands the inescapably negative environmental consequences of our nation’s current level of meat consumption, it makes me want to Hulk-smash when I hear a morning talk show host describe the ketogenic diet as an “all bacon” or “steak and bacon” diet. You could technically only eat steak and bacon and you would certainly be in ketosis. However, your proportion of saturated fat to monounsaturated fat intake would not be optimized for longevity, you would likely be missing several important micronutrients, your food bill would skyrocket, you would be disproportionately contributing to global warming, and you’d get really bored.
A HIGH-PROTEIN DIET. While it is true that you need to eat more protein than the standard daily recommended 0.8 grams per kilogram of body weight (in ketosis, you would probably increase your protein consumption to something closer to 1.2 to 1.5 grams per kilogram), it is by no means a high-protein diet. The ratios of your macronutrients should fall somewhere around 70 percent fat, 10 to 20 percent protein, and 5 to 10 percent carbohydrate. This should be described as a high-fat, moderate-protein, very-low-carbohydrate diet.
Why Use the Ketogenic Diet?
A well-formulated ketogenic diet is an amazing metabolic tool that will lead to changes in the way you look and feel. More than that, it produces very real physiological changes that have incredible implications for weight management, heart and brain health, and longevity. Unfortunately, it is also almost completely opposite to the dietary and health advice that our government has been selling for the past 45 years. This can produce quite a lot of cognitive dissonance in the discerning eater.
I whole-heartedly believe that for many people, a ketogenic diet (particularly the Ketogenic Mediterranean Diet) is the healthiest possible way to eat. Even with my education, clinical experience, and this belief, I still have moments when I think, “Goodness, I’m eating too much fat!” Don’t worry; if you were raised in the United States, these moments are natural. Fat has been the enemy all our lives. But this fervor for low-fat everything was more politically motivated than it was scientifically based. The evidence behind anti-fat rhetoric is sorely lacking, and the American people have been the subjects of a vast dietary experiment.
Unlike any other dietary pattern, the ketogenic diet is an all-or-nothing endeavor. Strictly speaking, you are free to have “cheat days” where you eat enough carbohydrates for your body to stop ketosis, but if you choose to do so you will most likely need to go through the initiation and adaptation phases again. That hardly seems worth it for a slice of pizza. This fact can be a bit off-putting to some people but as you will see in the coming chapters, once you start living the high-fat, high-energy, and fantastically delicious Ketogenic Mediterranean Diet, you will have no desire to go back to the Standard American Diet and the energy roller-coaster, excess weight, and increased risk of disease that come with it.
A ketogenic diet is not for everyone because not all of us have issues with the metabolism of carbohydrates. However, I think there is a good argument to be made that somewhere in the range of two thirds of the population does not deal with excessive carbohydrate intake very well. If you are one of these individuals, a ketogenic diet is the way to take back control of your health.