Tips for supporting long-term success on low-carb diets

By Dr. Evelyne Bourdua-Roy, MD, Dr. Andreas Eenfeldt, MD, Dr. Bret Scher, MD

Low-carb diets are an effective tool for helping people lose weight, reverse markers of diabetes and metabolic syndrome, and improve overall health. However, eating low carb only works if done consistently. It’s no secret that most people struggle with changing their dietary patterns. While anecdotally many clinicians feel this is much improved on a low-carb diet, it still is far from easy. In this guide, we provide tips and tools to better equip you to help your patients with long-term success.

This page is organized in the following sections:

• Diet troubleshooting
  Queries about hunger, protein amounts, weight stalls, gaining weight, allergies, fat intake, vegetarianism, achieving ketosis, and diet during women’s cycles.
• Family, medical, or social supports
  Queries about maintaining the diet with non-supportive spouse, health practitioners, children, family and friends, low incomes, busy travel.

Diet troubleshooting

1. Weight is stalling or increasing
2. Allergy to nuts
3. Female patients with cycle-related weight gain
4. Ketosis cannot be obtained or maintained
5. Patient is vegetarian
6. Patient is fat phobic
7. Patient’s ketone levels are high

1. Weight is stalling or increasing

Weight can fluctuate by two or more pounds from one day to the next simply from fluid retention. A temporary weight gain does not mean your patient is gaining fat. Remember that the scale is not the best indicator of success. Waist circumference and how clothes fit are usually better ways to evaluate progress.

However, if weight is definitely increasing without a reduction in waist circumference, ask your patients about the following potential problem areas:

• Eating snacks between meals.  Encourage them to eat two to three meals per day without snacks. They can increase protein and fat at meals to keep full and reduce snack cravings.
• Consuming lots of nuts, dairy or excessive fat. Eliminating snacks will help, as will removing added fat from coffee or tea.
• Eating close to bedtime. Recommend eating the last meal at least three hours before sleep. Adhering to time-restricted eating helps with this.
• Drinking daily alcohol. Encourage patients to stop drinking or switch to low-carb alcohol options.
• Consuming too much or too little protein. Too little can stimulate hunger, and too much can increase calories and potentially gluconeogenesis. Optimal protein intake is likely in the range of 1.2-1.7 g/kg of lean body mass per day.
• Eating beyond satiety. Advise patients to eat slowly, start with small portions, wait to register hunger signals, and only go for second helpings if hunger pangs persist.
• Chronic stress or inadequate sleep. Encourage meditation, stress reduction, and better sleep hygiene.  

See Diet Doctor’s tips for losing weight:

Top 10 tips to lose weight on low carb or keto for women 40+

How to lose weight

Hunger persists

Help your patient learn to ask, “Is this really hunger?” Sometimes we mistake hunger for what is really stress, boredom, or cravings. Sometimes we eat simply because others are eating or because the clock says it’s time to eat. Sometimes we feel hunger when we are actually thirsty, anxious, or tired.

If it is truly hunger, your patient may not be eating enough protein or fat, or both.

See below for guidance on determining how much protein is “enough”.

Encourage hungry patients to increase fat intake at meals, making sure they are satiated at the end of the meal. If they are struggling with time-restricted eating (TRE) or intermittent fasting (IF), it may be too soon for them. They should go back to eating three meals per day for a couple of weeks and then try TRE or IF again.

Remember that for decades we have been taught to avoid hunger. Most people will need time to understand their hunger cues and respond to them in a way that helps them achieve their health goals.

How much protein is enough?

Protein recommendations can differ between practitioners and specific needs of individual patients. However, despite apparent differences, protein consumption for most patients  should remain moderate, between 1.2 to 1.7 g/kg of lean mass per day.

It is always best to have a rough idea of your patient’s body composition since protein goals are based on lean body mass and not total weight. If it is not possible to obtain that information from a DEXA scan, hydrostatic weight or other reliable method, then use the patient’s reference body weight in kilograms to calculate protein needs.

If a patient is sedentary, aim for the lower end of the spectrum. If the patient is active,  recovering from sickness or surgery, or elderly with sarcopenia, it may be better to aim for the higher end of the protein range. The key is to not have them go too much above or below the reference range.

One of the main concerns with protein is that it can stimulate the production of insulin, which may be of particular concern in patients with diabetes.¹ However, it also stimulates the production of glucagon, which can decrease hunger and food intake.²

Although the liver can theoretically turn excessive protein into glucose and thus body fat, ingested protein normally has little impact on glucose levels.³ If patients are not losing weight or are not seeing significant ketone generation, check that their carbohydrate intake is low, they are not snacking between meals, and they are not consuming excessive fat. If none of those are issues, then ask them to calculate protein intake to see if they are over- or under-eating protein.

Some patients may need to temporarily reduce their protein intake to about 1.0 g/kg of lean mass if they are struggling to get into ketosis. However, we still need to ensure they have adequate protein intake long term to avoid sarcopenia and to promote building lean body mass. Therefore, approach protein reduction as a temporary trial rather than a long-term change.

Learn more about protein recommendations in our guide, Protein on a low carb or keto diet.

2. Allergy to nuts

Many patients worry they cannot do LCHF or keto successfully if they cannot eat nuts. Many low-carb recipes — especially ones for keto bread, pancakes or other replacement high-carb products — rely on nut flours, especially almond flour.

Nuts may be useful, especially at first when adapting to this new way of eating, but they are not necessary for success.

Coconut flour can be used instead because coconuts are not part of the nut family. Recipes will need to be adjusted, as coconut flour requires more liquid. (Note: Lupin flour should not be used, as there is a risk for cross-allergy with nuts.)

Even better, encourage your patient to focus on whole foods without nut products, as they are not necessary for a nutritionally complete, low-carb diet.

3. Female patients with cycle-related weight gain

Weight gain around the menstrual period is common for women, usually due to increasing water retention.

However, cravings and staying on-plan with a low-carb diet can also be difficult for some women, especially at the premenstrual time of the cycle. Here are ways to patients deal with cravings  include:

• • Recommend reducing or eliminating sugar substitutes during other times of the month to reduce the taste for sweet foods.
  • Alternatively, if sweeteners are generally not used but the patient craves sugary foods during the premenstrual phase, suggest using non-caloric sweeteners during this time only. 
  • Eating pork rinds or cheese can remedy cravings without spiking insulin or glucose.
  • Low-carb substitutes for high-carb foods — such as Fathead pizza, keto pancakes, or keto brownies — can satisfy a craving without undermining progress toward health goals.

Help your patient understand that this is a common occurrence, and if it happens to them, they should prepare for it, instead of getting caught off guard every month.

4. Ketosis cannot be achieved or maintained

This is not uncommon in the early stages of a low-carb diet. It usually takes time for the body to enter and stay in ketosis, even when the diet is very low in carbs. This depends on many factors, including the severity of baseline insulin resistance.

Verify why patients want to be in ketosis and if not being consistently in ketosis is causing them stress. They may think they need to be in ketosis in order to lose weight or reverse their diabetes, which is not true.

Asking your patients to keep a detailed food journal or use a macro-calculating app might reveal hidden carbs.

If patients are using urine strips to verify their ketone levels, this might not be reliable after a few weeks of ketosis, when the kidneys begin reabsorbing ketones more efficiently. Patients may want to invest in a blood ketone meter if results will provide information and motivation to stay on the diet. Learn more in our guide to testing ketones.

If a patient clearly benefits from being in ketosis and there isn’t an obvious dietary fix, you can also consider time-restricted eating or intermittent fasting to help maintain ketosis.

5. Patient is vegetarian

A nutritionally complete, low-carb vegetarian diet is challenging but completely possible.  The main concerns are eating too much carbohydrate and not enough protein. Yet with proper attention to eating legumes and tofu, non-starchy vegetables, dairy and eggs, you can reassure your patients who choose a vegetarian diet that they can do it. However, since vegetarians may be more likely to over-do carbs compared to non-vegetarians, they may need to track their intake of carb grams, at least in the beginning, to ensure they are staying below their carb goals.

Read more in our evidence-based guide, How to follow a healthy vegetarian keto diet.

A healthy, nutritious LCHF vegan diet is even more challenging but also doable with proper attention and supplementation. Again, make sure your patients who choose a vegan diet are not over-consuming carbohydrate and that they are getting adequate protein for long-term health.

You can read more details in our evidence-based guide,  How to eat low carb as a vegan.

6. Patient is fat phobic

After more than 40 years of low-fat messages, some patients have a strong distaste for or even outright fear of fat.  Success on a LCHF diet, however, usually means at least some increase in fat consumption, even if it a small one. While there is no need to consume fat bombs or add butter and oil to everything, patients should feel comfortable adding enough fat to their diets to feel full at meals and to enjoy their foods.

The following advice is for patients who are fat-phobic and who also need to add fat to their diet in order to reduce hunger and avoid under-consumption of calories. As noted above, adding too much fat to the diet when it is not needed can prevent patients from using their own body fat for fuel, which can lead to a stall in progress toward health goals:

• Add avocado or olive oil to vegetables and salads.
• Add one to two tablespoons (15 to 30 mL) of fat, such as butter, to each meal.
• Add cream, MCT oil, or coconut oil to coffee or tea in between meals.
• Take a tablespoon (15 mL) of whipping cream, MCT oil, or coconut oil on its own when feeling lethargic.
• Have a fat bomb for dessert.

Note: Warn patients to be careful with MCT oil, as taking too much too fast can cause diarrhea. This oil is almost tasteless and can easily be added to coffee or tea. We suggest starting with a teaspoon or less and increasing gradually.

Fighting fat phobia: changing fat from feared to revered once again

7. Patient’s ketone levels are high

Some people have a higher threshold before their bodies halt the production of ketones. While optimal ketosis is anywhere from 0.5 to 3.0 mmol/L, some patients will register levels between 4.5  and 6 mmol/L. This seems high, but it is still far from the ketoacidosis zone of 10 mmol/L and above.

Higher ketone levels do not necessarily mean more weight loss is happening or that the body is using ketones properly. Ketones can also increase with fasting and exercise or may simply “run high” without a clear explanation.

In addition, higher ketone level can occur secondary to your patient eating large amounts of coconut or MCT oil. After absorption into bloodstream, MCTs go straight to the liver, where they can be converted into ketones. If this is the case, the patient should cut back on added fat, as this may be preventing the body from burning its own fat stores.

Check that your patient is eating enough protein at each meal, especially if vegan or vegetarian. A lack of protein may increase the production of ketone bodies as a form of starvation ketosis.