How to handle difficult low-carb cases
It is organized in the following sections:
- Health markers or lab results
Queries about lab tests results for triglycerides, cholesterol/lipids, uric acid, CRP, HbA1c, fasting glucose, fasting insulin, liver enzymes, microalbumin, low blood glucose, high ketones.
- Pre-existing health issues
Queries about patients with pre-existing bariatric surgery, gout, gall bladder issues, kidney stones, fatty liver, pancreatitis, statin prescription.
- LCHF symptoms or side effects
Queries about keto rash, insomnia, cramps, GERD, headache/migraine, hair loss, palpitations, nausea, cold, fatigue/lethargy, bad breath, constipation, diarrhea, menstrual cycle changes.
- Diet compliance or success
Queries about hunger, protein amounts, weight stalls, gaining weight allergies, fat intake, vegetarianism, achieving ketosis, diet during women’s cycles.
- Family, medical, or social supports
Queries about maintaining the diet with non-supportive spouse, health practitioners, children, family &friends, low incomes, busy travel.
Health markers or lab results
On the low carb high fat diet (LCHF) or keto diet most health markers and lab results improve. Here is how to trouble shoot some unexpected results.
- Triglycerides are rising
- Total cholesterol/LDL is rising
- Uric acid is rising
- Inflammatory markers are rising
- Fasting insulin is rising
- Liver enzymes are rising
- Fatty liver has not improved on abdominal ultrasound
- Blood sugar levels are increasing or staying high during the day
- Blood pressure is not improving
1. Triglycerides are rising
Fasting triglycerides are expected to go down with an LCHF diet because they are being used by the body as energy, replacing glucose as the body’s main fuel. However, TGs are greatly influenced by diet, so they can vary throughout the day.
If TGs are rising, it could be transient due to rapid and significant weight loss. Check diet compliance, alcohol consumption and whether the patient had properly fasted prior to giving the blood sample.
Redo the test in 3 months.
2. Total cholesterol/LDL is rising
A low-carb, high-fat diet usually results in improved cholesterol profiles.
Typically HDL cholesterol increases while triglycerides decrease and LDL particles become larger and fluffier. All three of these changes statistically reduce the risk of future heart disease.
However, LDL cholesterol might go up on a low carb or ketogenic diet. Sometimes the increase is not significant, other times, especially with lean people, it can skyrocket. LDL is a weak risk factor, or surrogate marker, for cardiovascular disease. LDL increases need to be put in context with other risk factors.
Short answer: Retest in 3 to 6 months.
On average, the elevation of total and LDL cholesterol is so small that most studies do not even pick up on it.
One study found patients who maintained two years on a low-carb, high-fat diet showed a reduction of atherosclerosis – with fewer signs of heart disease. However, potential problems, if rare, exist.
A smaller number of people – 1-2 percent of the population – have worrying elevations of LDL and total cholesterol. Take this potential risk seriously and take steps to correct it.
For example, a small subgroup of people, probably due to genetics, can end up with total cholesterol numbers over 400 mg/dl (10 mmol/l) on a strict low-carb diet, and LDL numbers over 250 mg/dl (6.5 mmol/l). This is not normal. Even if the lipid profile is otherwise good – with high HDL and low triglycerides – it may be unhealthy.
In such cases the LDL particle count is high and the apoB and apoB/A1 ratio values abnormally high. These numbers all indicate an increased risk of heart disease.
What can be done to prevent or minimize the impact?
If this scenario impacts patients, advise them to do the following, in this order:
- Stop drinking bulletproof coffee: If patients stop drinking fat, such as butter, coconut oil or MCT oil in coffee, or drinking other fats when not hungry, this alone can often normalize LDL cholesterol levels.
- Eat only when hungry and consider adding intermittent fasting to their daily routine (IF consistently reduces cholesterol levels).
- Use more unsaturated fats, like olive oil, fatty fish and avocados instead of saturated fat. Whether it will improve their health is unknown, but it will lower their cholesterol.
- Consider whether the patient really needs to be on a strict LCHF diet. A more moderate or liberal LCHF diet (e.g. 50–100 grams of carbs per day) can still achieve good results and will likely lower their cholesterol. If they decide to increase their carbs, recommend good unprocessed carb sources, such as sweet potatoes, and not a resumption of eating wheat flour or refined sugar.
Should you prescribe a statin?
When cholesterol is high the question of taking cholesterol lowering medication — statins — is often discussed. These drugs do lower cholesterol but at the risk of very real side effects, like reduced energy, aching muscles, diabetes type 2 and a marginally reduced IQ.
As a general guideline, if the patient is at high risk of heart disease, five years of taking a statin drug can reduce their risk of a heart attack by 1 percent and lengthen their life by about 3 days. This must be discussed with your patient, to see whether it is worth the risk of side effects.
These relatively small statistical benefits are a best-case scenario, as they are based on pharma-funded studies. The movie Statin Nation exposes the exaggerations and the misleading, almost criminal, marketing of these daily drugs to people who don’t need them.
Effective lifestyle changes can have a far larger impact on your patients’ heart health than taking a statin drug, without the side effects.
3. Uric acid is rising
Serum uric acid levels can go up in the first 6-8 weeks of starting a low carb diet. It usually improves afterwards. Some people, naturally, have a higher uric acid but it doesn’t necessarily mean they will develop gout.
Retest in 2-3 months if necessary.
See the section ‘Pre-existing health issues’ management where there is a pre-existing history of gout or a gout flare.
4. Inflammatory markers are rising
Many factors can influence the results of the C-reactive protein (CRP) or high-sensitivity-CRP test (hs-CRP). Infections, even a simple cold, can increase this marker, as can bowel issues, such as food intolerances. Look for alternate causes, and repeat if necessary in 3-6 months.
5. Fasting insulin is rising
Fasting insulin levels are influenced by stress, fatigue and other factors and so rising levels are not a direct and faithful indicator of insulin resistance. Interpret results in the context of other markers of insulin resistance, such as fasting glucose and HBA1c.
Retest in 3 months or do a 2-hour postprandial insulin, to get a more detailed picture of the situation.
6. Liver enzymes are rising
Liver enzymes, measured by the alanine aminotransferase test (ALT), can go up in the first few weeks of switching to a low carb diet or with significant weight loss. Eventually, they almost always go down.
If ALT does not go down or even increases after a few months, and weight is stable, check for diet compliance, and seek out other causes not related to diet, including alcohol consumption.
7. Fatty liver has not improved on abdominal ultrasound
For liver steatosis to improve by the first 6 months, a significant amount of weight needs to be lost or low sugar levels need to be sustained for many weeks. People who fast regularly tend to have better results at 6 months.
For many patients, however, it will take longer than 6 months for fatty liver to improve. Check again with ultrasound at 12 to 24 months.
8. Blood sugar levels are increasing or staying high during the day
Higher blood sugars are usually only observed during periods of weight-loss. There are pockets of sugar in fat cells. As fat cells empty, they can cause transient increases in blood sugar levels. It takes time to normalize.
If BG remains high, ask the patient to keep a food journal and check for hidden carbs, excess protein, snacks, and drinks. Focus on time restricted feeding and intermittent fasting.
ADD here about checking for LADA is BG is still high or increasing? Dawn phenomenon and adaptive glucose sparing if particularly high in morning?
9. Blood pressure is not improving
Most people adopting the low carb diet will see their blood pressure decrease, but a few may have blood pressure remain elevated or even rise.
This can be seen in patients who are fasting because of the adrenaline produced in the fasted state.
Ask your patient to decrease the duration of the fast or stop fasting altogether to focus instead on time restricted eating until their body adapts. Some people adapt more slowly to being in a fasting state.
Pre-existing health issues
- History of gout/hyperuricemia
- History of gallbladder issues
- History of kidney stones
- History of bariatric surgery
- History of statin use
1. History of gout/hyperuricemia
Can patients with a history of gout do the LCHF diet? Yes, definitely, but they may have a gout flare in the first six to eight weeks.
Patients with a history of gout may need to stay on existing treatment or have prophylactic treatment added, such as using a short term prescription for allopurinol.
Over the long term, uric acid levels tend to become lower on low carb, along with other markers of metabolic syndrome. One study showed uric acid going down significantly after 6 months on low carb, suggesting it may decrease the risk of gout, eventually enabling gout patients to become gout-free.
It might take months or even years, however, to completely reverse gout patients’ underlying metabolic syndrome, especially their insulin resistance, and to achieve normal uric acid levels.
Will the LCHF diet precipitate gout in some patients without a history of gout?
While short term studies show a temporary rise in uric acid during the first few weeks when starting a strict low-carb diet, doctors regularly treating patients with low-carb diets do not notice an increase in gout episodes. An increase in risk during the first few weeks is likely small or moderate, with uric acid returning to baseline or even lower.
Clinical observations from low-carb physicians:
- Almost all uric acid levels return to normal within 6 to 8 weeks
- Patients who have a previous history of gout are the most at risk for developing a gout attack in the first six to eight weeks. Adjust medications accordingly or discuss prophylaxis if necessary
- Patients who do not have a history of gout will likely not experience it even if their uric acid levels go quite high.
What else can be done to prevent or minimize a gout flare?
Along with medication support, as stated above, doctors can encourage their gout patients to:
- Minimize sugar intake: Gout is strongly related to obesity, type 2 diabetes and metabolic syndrome, so consumption of sugar and refined carbohydrates, too, may be at its root. High blood levels of insulin have been shown to increase uric acid levels, probably by decreasing the excretion of uric acid by the kidneys. Moreover, gout epidemiology parallels populations’ sugar consumption (e.g.18th Century Britain, at the birth of its sugar industry.) Fructose consumption is also strongly linked to uric acid levels.
- Reduce alcohol consumption: Beer and other high-carb alcoholic beverages are of particular concern, but all alcohol consumption should be minimized.
- Drink water with lime or lemon: Add 1-2 tbsp of unsweetened lime or lemon juice to water throughout the day in the first six to eight weeks of LCHF. Citric acid neutralizes uric acid and may reduce uric acid levels.
- Take cherry root extract: Available in health food stores as black cherry root extract or as tart, unsweetened cherry juice, it may reduce uric acid levels during the first weeks of LCHF. It has been used for many years by nephrologists to help prevent gout attacks in renal patients who can no longer take medications such as allopurinol.
2. History of gallbladder issues
Traditional medical advice is that a diet high in fatty foods can predispose patients to the creation of gallstones, gallbladder attacks, and even the eventual need to remove the gallbladder.
Does this mean patients with a history of gallstones, or gallbladder removal (cholecystectomy) cannot eat a low carb high fat diet? No, not at all.
Evidence is mounting that in fact a diet low in fat and high in carbohydrates may increase the risk of the creation of gall stones. The theory is a low fat diet causes the bile to sit idle in the gallbladder rather than flush it regularly with the need to digest fat in the diet, spurring the creation of stones. Three studies have confirmed this low fat risk of gallstones here, here and here.
After stones are formed, when a higher fat food is then consumed and bile released from the gallbladder, the stones can get stuck in the bile duct, flaring symptoms, which are typically extreme pain in the top right portion of the abdomen, radiating to the back.
What doctors need to know
The following advice may help your patients with gall bladder issues on a LCHF diet:
- Asymptomatic patients: if stones have been visualized or confirmed, but the patient has no symptoms, there is no need to do anything. Their stones may never be an issue.
- Symptomatic patients: If they experience severe pain after eating low carb/keto meals, they may need to reduce their lipid intake, break it up into smaller portions throughout the day. and/or use coconut oil and MCT oil as their main fat, as both have no hepatic passage. If these methods do not reduce attacks they might need eventual elective surgery, or be placed on specific drugs to manage their stones.
- Patients without a gallbladder:An LCHF diet can be consumed when the gallbladder has already been removed, but patients may need to eat smaller more frequent meals, with smaller amounts of fat at any one time. The liver still makes bile to digest the fat, but the gallbladder can no longer concentrate and store it. Bile is released directly into the intestine. Along with consuming coconut and/or MCT oil, which by-passes the liver, consuming an ox-bile supplement can help break down fats and reduce diarrhea or other digestive symptoms. Consumption of low carb, above ground vegetables, or keto bread, with meals can also help slow digestion of the fat and prevent diarrhea.
Will LCHF improve or dissolve gallstones?
No formal study has yet tested an LCHF diet on people with gallstones.
However, anecdotally, many people report having their gallstone symptoms eventually disappear on a LCHF diet, sometimes after an initial gallstone attack..
In a survey of members of a Swedish low carb site, below,145 people who used to have gallstones reported their experience. The vast majority (80%) had symptoms improve or disappear on LCHF, giving support for the theory that higher fat food can improve gallbladder disease. (Note, however, this kind of self-selected survey gives unreliable answers.)
3. History of kidney stones
Some but not all people starting a LCHF/keto diet may need to increase their salt intake to combat higher salt excretion from the kidneys and to reduce the symptoms of induction or keto flu.
For patients with a history of kidney stones, doctors may be uncomfortable recommending higher salt intake.
Wait and see if patients develop symptoms of sodium deficiency, such as headache, fatigue, lethargy, muscle weakness, nausea, muscle cramping. If these symptoms arise, then advise the patient to increase salt consumption. However, advise them to restrict other-stone forming low-carb foods such as caffeine, chocolate, spinach, okra, swiss chard, rhubarb, sweeteners, red meat, sardines, carbonated water and dairy.
Once the patient stops exhibiting symptoms of hyponatremia, suggest patients try to reduce excess sodium consumption. Most patients do not require sodium supplementation after the first month or two.
4. History of bariatric surgery
Increasingly, more patients are coming to the LCHF diet after having had bariatric surgery. It is preferable, of course, that patients attempt a trial of the diet before life-altering surgery. — as it may remove the need for surgery completely. However, post bariatric surgery, LCHF or a keto diet can be a valuable, even essential, addition to long term success and permanent weight loss and diabetes reversal.
Avoidance of carbohydrates and adherence to a strict LCHF/ketogenic diet can remove the strong cravings, sugar addiction and compulsion for binge eating that may underlie patients’ past struggles with obesity.
Patients who have had bariatric surgery are safe to fast, but they cannot eat one large meal in very restrictive eating window. It is better for them to graze over a six-hour restricted time period rather than eat two larger meals within a six-hour window.
Increasingly, evidence is showing that carbohydrates are highly addictive substances that release endorphins and provide pleasure and significant, but often dysfunctional, emotional regulation. In fact, many recent studies show a strong risk for addiction transference from food to other substances, such as alcohol and gambling, in patients after bariatric surgery.
Long term success of patients with bariatric surgery, along with the LCHF or ketogenic diet, may also rely on doctors helping patients address their emotional triggers for eating carbohydrates and other foods, such as helping them deal with feelings of anxiety, stress, depression, anger, fear, pleasure, boredom and other uncomfortable emotions that they may have self-medicated with carbohydrates.
5. History of statin use
Many patients, who start the LCHF diet, may want to stop taking a previously prescribe statin. Many patients have been put on unnecessary statins. Before stopping the prescription explain the pros and cons, the number needed to treat and the number needed to harm in primary and secondary prevention.
This Diet Doctor guide can help you and your patient decide whether to stop statins.
If the statin was started by another healthcare professional, such as a specialist who still follows your patient, encourage your patient to also discuss the issue with that specialist.
A trial of 8 weeks without a statin could be done, with a lipid panel afterwards to check levels.
When checking the lipid panel of your patient, it is important to also look at triglycerides and HDL. Both are expected to improve on a low carb diet, and together constitute a better marker of cardiovascular health than LDL levels alone.
LCHF symptoms or side effects
- Keto rash
- Muscle cramps
- GERD arises or worsens
- Feeling cold
- Lethargy and fatigue
- Hair loss
- Bad breath
- Changes in female patients’ menstrual cycles
1. Keto rash
Occasionally patients new to low-carb or ketogenic diets experience an intense, itching, usually symmetrical rash. It is most commonly observed on the back, under the armpits, around the neck and shoulders, down the chest and around breast tissue. Sometimes people experience it on their arms and legs as well.
While relatively uncommon, it is highly annoying, distracting and distressing for those who do experience the rash.
Why does it occur?
Theories abound about the root cause of this problem, but scientific data is very limited as to why it happens.
The common progression of the rash is:
- The itching usually starts soon after patients enter ketosis. It stops within a day or so if people eat more carbs and exit ketosis.
- It can often get worse in hot weather, or after exercising.
- The usual distribution of the itch and rash matches areas where sweat can accumulate.
This progression supports the notion that this itching may be caused by the ketones in sweat drying on the body, especially acetone which can be irritating in high concentrations.
What to recommend to patients to prevent or minimize the impact
- Reduce sweating: Wear comfortable loose clothing for the climate and use air conditioning when appropriate.
- Shower: Rinse the body well after exercise or on hot days to remove any irritants.
- Change exercise plans: Skip exercise for a few days or do something like brief weight training that does not produce perspiration.
- Exit ketosis and gradually re-enter: Allow the body to adapt more gradually to ketosis, by slowly lowering carb intake. See the apple cider vinegar protocol below
- Stay out of ketosis: Exiting ketosis will reliably cure the issue within a day or two. To still get benefits from LCHF – at least for weight loss and type 2 diabetes reversal – patients can do a more liberal low-carb diet (50-70 grams of carbs per day) and add intermittent fasting.
- Other treatments: There are many other treatments suggested online; like antibiotics taken for weeks or months and/or special creams. We ddo not advise oral antibiotics, as the side effects and risks are much worse than the doubtful and temporary benefits. Steroids, anti-fungal creams and anti-histamines appear not to be effective at all.
Some believe the keto rash is a result of candida die-off. Again, little scientific data supports this claim, but there is the possibility of developing fungal infections in these areas that become sweaty and itchy. Occasionally, a final infection can develop in these areas.
Apple cider vinegar protocol for the keto rash
Some low-carb physicians have found advising patients to consume raw, unfiltered apple cider vinegar internally a well as externally may help. This protocol may help patients clear a keto rash within 2-5 days and then get back into ketosis within 2 weeks without the rash reappearing or fungal infections developing:
- Use raw, unfiltered (cloudy) apple cider vinegar (with the “mother,” meaning the probiotic culture that is part of fermentation.)
- Internal use: add 2 tbsps to 1 cup water and drink. Do this three times a day for two weeks and then reduce to 1 tbsp of the vinegar in 1 cup of water three times a day for another two weeks.
- External use: mix equal parts vinegar and water and apply topically to the affected area twice a day for two weeks. Leave on for 15-30 minutes before rinsing off.
- Consume 1 cup of berries per day for 1 week
- Reduce the berries to ½ cup per day for a subsequent week
- Eliminate berries and continue with the raw, unfiltered apple cider vinegar, above.
2. Muscle cramps
Some people experience increased muscle cramping, particularly at night, on a low carb or keto diet.
Patients should drink plenty of fluid and consume enough salt. Once sodium levels become quite low, the body will start to sacrifice magnesium and then potassium in order to preserve sodium levels. The first line of muscle cramp prevention is to make sure sodium levels remain stable.
Second, suggest magnesium supplements. Many patients, formerly fuelled by carbohydrates, are magnesium deficient at the start of an LCHF diet, but this can be exacerbated if sodium intake is too low.
Recommended magnesium supplementation
- Magnesium bisglycinate or malate, 400 mg once a day to start, for patients who are prone to diarrhea or loose bowel movements, and/or for patients who also have chronic pain.
- Magnesium citrate, 400 mg once a day to start, for patients who are prone to constipation.
- Daily Epsom salt baths or foot soaks: dissolve 1-2 cups of Epsom salts (magnesium sulfate) in a bathtub or 1 cup in a foot soak. Soak for 15-20 minutes daily (or as often as possible) for the first 3 weeks or any time muscle cramping arises.
- Magnesium oil/gel: this can be purchased at a store or made at home and massaged into leg muscles. Homemade recipe:
- Bring 1 cup of distilled water to a boil
- Dissolve 1 cup of Epsom salts or magnesium sulfate into the boiling water and let the salts dissolve
- Once dissolved, let cool and then store in a bottle or spray bottle.
If muscle cramps continue, verify the dose, method, and regularity of magnesium supplementation. Increase the dose if necessary. If the increased dose results in loose stools, change the type of magnesium (bisglycinate has less impact on the GI tract), and/or split the doses between morning and night.
3. GERD arises or worsens
Gastroesophageal reflux disease (GERD) usually improves with a low carb or keto diet. However, some patients experience heartburn or indigestion in the first few weeks. This is rarely experienced by people who have no history of reflux.
Check if the patient abruptly stopped their PPIs, if they are drinking more coffee than usual, in particular on an empty stomach, or if they have been using NSAIDs recently or other drugs that can irritate the stomach.
What patients can do to minimize the impact
- Take their PPI medications as prescribed even on fasting days.
- Consume raw, unfiltered apple cider vinegar. Add 2 tbsps to 1 cup water and drink. Do this 3 times a day for 4 weeks and then scale back to 1 tbsp of the vinegar in 1 cup of water three times a day for another 2 weeks. This can be done prophylactically or to treat the onset of reflux.
- Drink lemon or lime juice in water. Citric juice is very alkalizing in the gut and can help neutralize stomach acid;1-2 tbsp in a glass of water a few times throughout the day can help prevent or treat reflux.
Some patients experience irregular or higher than usual resting heart rates. Palpitations can be due to dehydration and lack of salt.
Advise patients to drink enough water to stay hydrated and take enough salt. When carbs are reduced, less insulin is circulating, which means less retention of water and sodium.
Make sure patients are not deficient in magnesium; suggest supplementation if necessary.
If adding salt and water or supplementing with magnesium does not completely eliminate heart palpitations, cortisol being released to maintain blood sugar levels could be the issue. This is usually a temporary problem as the body adapts to a lower-carb diet and should go away within a week or two.
Antihypertensive medications may need to be reduced. Hypertension can often dramatically improve within the first few weeks of switching to low-carb. Decrease or discontinue diuretic medications first, which should help with palpitations.
In the uncommon situation that the problem persists – and the palpitations are bothersome to the patient – recommend they slightly increase their daily carb intake by 10-20 grams , and then slowly if heart rhythm normalizes, reduce their daily carb intake by 5 grams every two weeks. This will reduce the effect of the low-carb diet temporarily by gradually transitioning the body to burning ketones.
5. Feeling cold
Some patients, when switching from burning glucose to burning ketones, feel cold, especially when fasting. This is normal.
Recommended that these patients take an extra 15-30 grams of fat a day, which is approximately 1-2 tbsp of olive oil or coconut oil. This will help preserve their metabolic rate during this period of transition and help speed up the process of converting them to fat burners.
This does not usually last longer two months. Patients often report experiencing coldness at first, then suddenly, a few months later, intense feelings of warmth. This is a sign that the patient has become fat adapted. The patient at this point should stop consuming any extra fat, and resume eating to satiation.
6. Lethargy and fatigue
Again, this could be due to lack of sodium and water. Patients tend to be scared to consume more salt than standard recommendations.
On a low carb/keto diet, especially in the transition period, more sodium and water are necessary to compensate for an increased diuresis caused by a drop in insulinemia. Insulin tells the kidneys to retain water and salt. If less insulin is circulating, the kidneys will start flushing out more water and more salt.
Fatigue may also arise in patients who have reduced their carb intake but not added in enough fat in their diet. Many people understand the concepts of a low carb diet intellectually, but have a hard time, due to long standing fat phobia, adding more fat to their diet.
Other reasons for lethargy and fatigue could be:
- Magnesium deficiency: see the section on muscle cramps for magnesium supplementation advice..
- Vitamin D deficiency: suggest supplementation with XXX mg and 15 minutes of sun exposure, without sunscreen a day..
- Anemia (iron, or B12 and/or folate deficiencies), especially if they are vegan, vegetarian, chronically on PPI’s, or post bariatric surgery.
- Poor sleep. Some patients report having sleep disturbances when they go keto. This is usually temporary and disappears in time and with magnesium taken at bedtime. See the next section on insomnia.
In the switch to a low carb diet, some people experience disrupted sleep. The main reasons are:
- Dehydration: increased salt and water can help.
- Low magnesium: a magnesium supplement at night can improve relaxation and sleep.
- Excessive energy: some patients experience such a surge of energy with a low carb diet, they feel revved up at night. This will improve with time, usually within 2-4 weeks. Meditation can also help, such as through downloadable smart phone apps.
Insomnia during intermittent fasting
Occasionally patients report difficulty sleeping if intermittent fasting is part of their routine. While this only lasts for the first 2-4 weeks of IF it can be frustrating, tiring and undermine success.
Why it happens?
During fasting the body produces adrenaline. Patients often find themselves wide awake when they would rather be sleeping. The body learns to adapt to this increase in adrenaline if the patient continues to fast consistently. Stopping and starting the fasting because of sleep disturbances or due to life circumstances that interrupts regular fasting often prevents adaptation.
How to prevent or minimize the impact
- Fast consistently. This will allow for the body to adapt to the higher adrenaline levels.
- Be patient. This will almost completely resolve with two weeks. Encourage patients to start fasting during a non-stressful time.
- Take a magnesium supplement. Magnesium has the opposite effect of adrenaline on cells. Magnesium bis-glycinate or malate taken 3 to 4 hours before sleep is best for patients who are prone to diarrhea or loose stools. Magnesium citrate is best for patients who are prone to constipation. Start with 400 mg once a day a few hours before sleep, because it takes time for the magnesium to be absorbed by the body for relaxation.
- Take an Epsom salt bath or foot soak in the evening before bed. Transdermal magnesium will have a much more rapid effect than the oral supplementation. It can also have other calming and stress reducing effects on the patient.
Changing diets usually means a change in the microbiome. Some adjustment to bowel habits and regularity might occur.
If patients complain of constipation, advise taking lots of water and salt and magnesium supplementation, particularly magnesium citrate.
Extra fibre may also help. Eat a pudding of chia seeds soaked in coconut cream or take 1 to 2 tablespoons of psyllium husk with water, ground flaxseeds, coconut fat, and MCT oil one to three times a day.
Diarrhea can also happen, especially under the following situations:
- When people are not used to eating a lot of fat or when they are consuming MCT oil. Fat ingestion, especially MCT oil, may need to be started in small quantities and progressively increased.
- Using a lot of sugar alcohols, such as the sweeteners erthyritol, xylitol, mannitol, and sorbitol in low carb baking, treats or drinks.
- Drinking large quantities of broth or coffee, particularly during a fast.
Diarrhea should resolve by itself after a few days of adaptation. If it doesn’t and it’s not caused by an identifiable agent, sugges patients try adding psyllium, ground flaxseeds or chia seeds to their diet (1 or 2 tablespoons, 1 to 3 times per day).
Nausea may be caused by a lack of salt and water or by a sudden and significant increase in fat consumption, especially in someone used to eating a very low fat diet.
A change in medication, such as adding metformin, can cause nausea. Exogenous ketone supplements and MCT oil may also cause nausea in some people.
If your patients experience nausea and are diabetic, check their blood glucose and ketone levels.
Headaches usually arise during the transition to burning ketones as part of keto flu, but may occur anytime due to lack of salt and water, excessive coffee consumption and stress. A few shakes of salt into a glass of water can often relieve a headache within 10 to 15 minutes.
12. Hair loss
Temporary hair loss can occur for many different reasons, including big dietary changes, especially ones that includes rapid weight-loss, especially through severe caloric restriction. While LCHF does not restrict calories, temporary hair loss can still take place.
If it happens, it is usually around 2-6 months into their new way of eating. It tends to last about 3 months. Eventually the hair grows back.
To reduce hair loss, make sure patients are eating enough calories and have adequate fat and protein intake. Suggesting that patients increase their protein by about 10-20 grams per day may help, and may also improve weight loss and reduce stress.
If that doesn’t seem to help and the problem persists, and they are consuming adequate calories, it could be due to:
- Usually demanding physical exercise
- Breast feeding
- Nutrient deficiencies
- Psychological stress
Hair loss because of pregnancy and breastfeeding usually resolves with time. Other issues, related to mental and physical stresses, may need to be addressed by other methods.
13. Bad breath
People often report experiencing a strange taste in their mouths or foul breath once they start a strict low-carb diet and go into ketosis. This is the result of the ketone body acetone, and the taste or smell is often described as fruity that reminds them of nail polish remover. Reassure your patient that this is actually a good sign: their body is burning fat.
This doesn’t happen to all people switching from carb-burning to fat-burning. It usually lasts for only a week or two until the body adapts and stops “leaking” ketones through breath and sweat.
Occasionally, this bad breath persists throughout their weight-loss journey. Patients may also develop a harmless white film on their tongue.
How to minimize the impact
For patients concerned with bad breath, suggest the following actions:
- Drink plenty of fluid and consume enough salt. A dry mouth means less saliva to wash away bacteria. Stay well hydrated.
- Maintain good oral hygiene. Brush and floss teeth regularly. For example, higher meat consumption can mean more meat gets stuck in teeth. While good oral hygiene won’t stop the fruity smell since it comes from the lungs, it will reduce other causes of bad breath.
- Use a breath freshener regularly. This can help mask the odour.
- Give it time. the odor will likely reduce in two to four weeks of regular ketosis.
- Reduce the degree of ketosis. If the smell is a long-term problem that is creating significant personal distress, introduce a few more carbs into the diet. Usually 50-70 grams per day is enough to drastically reduce their degree of ketosis or take them out of ketosis entirely. Then gradually go back into ketosis by reducing carbohydrates by about 5-10 gram per week every 2 weeks.
- Try oil pulling. Swirling a tablespoon of olive oil or coconut oil in the mouth can increase lubrication and cleanse the mouth of other bacteria. Swish it around and “pull” it through the teeth. Do not swallow. After 15 to 20 minutes, spit it into a garbage can, not down the sink (it may clog drains.) Then rinse with salt water and brush teeth.
14. Changes in female patients’ menstrual cycles
Changes in the menstrual cycles are frequent at the start of LCHF or keto eating. Some women, especially those with polycystic ovarian syndrome (PCOS), even start experiencing regular menstrual cycles for the first time in many months or years.
Some women may experience irregular cycles in the first few months of starting LCHF. This usually resolve on its own.
For women with PCOS and previous irregular cycles or even infertility, caution patients that their fertility might increase suddenly on a low carb diet. They may need to use more consistent contraception if a pregnancy is not wanted.
Diet compliance or success
- Weight is stalling or increasing
- Allergy to nuts
- Female patients with cycle-related weight gain
- Ketosis cannot be obtained or maintained
- Patient is vegetarian
- Patient is fat phobic
- Patient’s ketone levels are high
1. Weight is stalling or increasing
Weight can fluctuate by quite a few pounds from one day to the next. It usually is due to fluid retention, not the gaining of fat. Often the scale is not a reliable indicator of success. Waist measurements of the fit of clothing can be a better indicator.
If the weight is definitely increasing, check the diet and eating schedule to see if patients are:
- Eating snacks between meals. If so, cut them out.
- Consuming lots of nuts, dairy and or excessive fat. Cut out or reduce consumption.
- Eating close to bedtime. Stop eating more than 3 to 4 hours before sleep.
- Drinking daily alcohol. Reduce consumption.
- Consuming too much protein. Reduce protein amounts.
- Eating beyond satiety. Eat slowly, start with small portions, wait to register hunger signals and only go for second helpings if hunger pangs persist.
- Under a lot of stress or not sleeping well. Try meditation and stress reduction, and better sleep hygiene.
See Diet Doctor’s tips for losing weight.
Persistent hunger can interfere with the success of the LCHF diet. Hunger often means patients are not consuming enough fat.
If hunger occurs between meals: increase slightly the fat intake at meals. Patients should eat to satiety and make it to the next meal easily, without hunger. However, if at the following meal, they are still not hungry, they should skip that meal, and slightly reduce their fat intake at the following meal.
Hungry during fasts: the first 24 hours are sometimes the most difficult. Advise patients to drink bone broth, tea of coffee; let the hunger pass like a wave; keep busy; focus on other things. Fasting gets easier with practice.
Patients should regularly ask: Is it really hunger? Sometimes we eat for other reasons: for stress, for boredom, for reward, because others are eating, because the clock says it’s supper time. Sometimes we feel hunger when we are actually thirsty, anxious or tired.
Protein amounts are confusing
Protein recommendations can differ between practitioners, individual patient needs and needs for diabetes reversal, weight loss, and athletic performance.
Protein consumption for most patients should remain moderate. The accepted ranges are from 0.6 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. If it is not possible to obtain that information from a Dexa scan or other reliable method, then use their ideal body weight in kilograms to calculate protein needs.
If a patient is very sedentary, aim for the lower end of the spectrum. If very active, lifting weights, recovering from sickness or surgery, or are elderly with sarcopenia, pregnant or breastfeeding, it may be better to go towards the higher range of protein.
One of the main concerns with protein is that it stimulates the production of insulin, and in excess, can be turned into glucose by the liver. Patients with diabetes who are consuming too much protein will usually have this reflected in higher blood glucose levels despite a LCHF diet.
If patients are not losing weight or is not seeing significant ketone generation, check first that their carbohydrate in take is low and they are not consuming excessive fat. Then suggest they try to scale back on their protein by 5 or 10 grams per day to see if that triggers weight-loss. .
If patients are not losing weight or not seeing significant ketone generation but are losing hair, then ask them to increase their intake of protein by 10 grams per day. Their body may be under stress from not having enough protein.
2. Allergy to nuts
Nut allergies are increasingly common. 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, as coconuts are not part of the nut family. Recipes will need to be adjusted, as coconut flour requires more liquid.
Lupine flour should not be used, as there is a risk for crossed allergy with nuts.
3. Female patients with cycle-related weight gain
Weight gain around the menstrual period is common for women. This is usually a shift in water retention.
However, cravings and compliance with the diet can also be difficult for some women, especially at the premenstrual time of the cycle. Check for diet compliance and sugar cravings. If present, other ways to deal with such cravings include:
- Reducing or eliminating sugar substitutes during other times of the month to reduce tastes for sweet foods.
- If sweeteners are generally not used, but sugary foods craved during PMS, suggest using non-calorie sweeteners during this time only.
- Eating pork rinds can help deal with junk food cravings, but not spike insulin or glucose.
- Low carb substitutes for high carb foods, such as fat head pizza, keto pancakes, keto brownies, can quell a craving without the loss of dietary control.
4. Ketosis cannot be obtained or maintained
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 the insulin resistance.
Verify why patients wants 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 necessary.
A food journal might reveal hidden carbs.
If patients are using urine sticks to verify their ketone levels, it might not be reliable after a few weeks of ketosis, as the kidneys become better at reabsorbing ketones. They may want to invest in a blood ketone meter if results will helps motivate, inform and sustain them on the diet.
5. Patient is vegetarian
A healthy low carb high fat vegetarian diet is completely possible. hile patients may be concerned about lacking protein, or their diet being too high in carbs if eating legumes and tofu, you can reassure them they can do it.
Remind them that there is a fair amount of protein in non-starchy vegetables. A vegetarian who eats dairy and eggs will have no problem. Encourage them to eat nuts, and seeds as part of their diet as well.
A healthy, nutritious LCHF vegan diet is very difficult.
6. Patient is fat phobic
After more than 40 years of low fat messages, some patients have a strong distaste, even morbid fear of fat. Success on the LCHF diet, however, requires that while they decrease carb consumption they must increase fat consumption — otherwise their bodies may assume they are starving and lower their basal metabolism rate to conserve energy.
Explain this necessity to the patient. Focus first of the patient’s preferred sources of fat and suggest they progressively increase the levels.
There are numerous ways to increase the daily fat consumption. Having a fat bomb for dessert is one of them.
Other practical tips:
- Add 1-2 tbsp of fat, such as butter, to each meal
- Add some fat to their coffee or tea, such as cream or coconut oil, in between meals
- Take a tablespoon of fat, such as whipping cream, MCT, or coconut oil, on its own when they are feeling lethargic
Note: warn patients to be careful with MCT oil, as it can cause diarrhea. This oil is almost tasteless, and can easily be added to coffee or tea. It is suggested to start with a teaspoon or less and increase progressively.
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 1.5 to 3.0 mmol/L some patients will register levels of 4, 5 and 6 mmol/L. This seems high, but it is still far from the ketoacidosis zone of 9 or 10 mmol/L and above.
Higher ketone levels do not necessarily mean more weight loss, and it doesn’t mean that the body is using ketones properly. They can be circulating and not used as much as they could, hence the higher level. This may happen at the beginnings with some patients.
It also can be secondary to your patient eating large amounts of coconut oil and MCT oil. Both are rapidly and easily converted to ketones by the body in the digestive tract (with no hepatic metabolism). They should cut back on the added fat as this may be preventing the body from burning their own fat stores.
Check that your patient is eating enough protein at each meal. A lack of protein may increase the production of ketone bodies as a form of starvation ketosis.
Family, medical, or social supports
- Unsupportive health care professionals
- Unsupportive spouse or family
- No time to prepare two meals for non-LCHF family
- Travel or life demands restaurant meals
- Low income
1. Unsupportive health care professionals
Since LCHF or ketogenic eating is not yet widely recognized as the standard of care for weight loss, diabetes reversal, or other health conditions, patients who may be having success with the diet may get conflicting or unsupportive messages from other people on their health care team.
This can cause considerable stress, confusion, or hesitation to continue the diet. This is situation is very tricky.
It is best to educate your patients about both the known benefits and risks associated with all dietary options — calorie restriction, low fat diet, LCHF, DASH diets etc. — and follow-up by suggesting that they can try each option and see how they feel. Encourage your patients to listen to their body and pay attention to their lab results. If one method doesn’t work after 30-days, then they can try the next method.
If the patient already feels well and is experiencing positive improvements with their lab results, be compassionate when the patient expresses concern about all the conflicting advice. It is a confusing time for patients.
Ask your patient how they feel about their health and diet? Have they noticed any improvement or the opposite? Review their lab results with them and point them towards low-carb resources where they can read patient testimonials.
2. Unsupportive spouse or family
This is definitely a tough situation and can significantly undermine patient success and ability to sustain the LCHF diet or intermittent fasting routines.
Suggest some of the following actions:
- Tell patients to ask their spouses and family to allow them the space to try it without criticism for 30 days. People tend to become more supportive of the person when they start seeing results.
- Advise patients not to discuss their diet and fasting schedule with friends and relatives. If asked, they can simply say they are focusing on eating plenty of vegetables and protein, and cutting out sugars
- Encourage the patient to join an online community such as the many on Facebook for ongoing support.
- If a patient’s teenage or adult children bring processed foods and junk foods into the home, ask them stop and only eat this food outside of the home. This isn’t always possible with partners, spouses and other adults. Tell your patient to ask these adults to avoid eating these foods in their presence.
It might be helpful to do follow-ups more frequently with such patients at first, as they are at higher risks to quit due to pressure from their families and friends.
3. No time to prepare two meals for non-LCHF family
All members of the family, especially children and teens, can benefit from eating less sugar and refined carbohydrates. There are dozens of delicious recipes on Dietdoctor.com that are family-friendly, satisfying and very popular.
Patients can be supported to keep meals simple, like preparing a portion of meat or fish, with green vegetables and olive oil.
If the rest of the family demands rice or potatoes, it can always be served on the side on their plates only.
Patients should avoid making one-dish starch-based recipes, like lasagna and shepherd’s pie, that are not low carb. Use recipes, instead, for low versions of these dishes. With time, these may become family favorites. Suggest families look through Diet Doctor recipes to choose recipes that appeal to them.
4. Travel or life demands restaurant meals
A heavy travel schedule at work, or family demands, such as a sick relative, may mean a period of grabbing food on the go from restaurants or fast food joints.
It’s possible to eat low carb in almost any type of restaurant, but it’s not necessarily going to be as healthy as home(less good quality meat, good cooking oils, etc.) But it will be fine for a while.
Burgers can be ordered without ketchup or bun, and wrapped in lettuce, or eaten with a fork, in almost all fast food restaurants. A chicken thigh with a side of Cesar salad (skip the croutons) is another easy option. Breakfast sandwiches can also be ordered without the bun and just the eggs, ham and cheese and eaten with a knife and fork.
In sit down restaurants, it’s usually possible to have a steak, chicken leg, or a filet of salmon. Skip the starchy sides, like baked potatoes or fries, and ask for green vegetables or a salad.
If a basket of bread is placed on the table, keep the butter, but ask the waiter to remove the bread.
It’s also possible to skip meals when traveling. A black or creamy coffee or tea can be found just about anywhere.
5. Low income
Some patients may have a low income or have a small food budget. Eating low carb or keto can be done on a low budget, especially if intermittent fasting is done throughout the week.
Some people complain the LCHF is expensive, but it doesn’t need to be. While there are many fancy recipes online with expensive ingredients, like almond flour, erythritol, maple extract, MCT oil, it is not necessary to bake or cook anything elaborate. Avoiding refined and processed foods and junk foods can reduce food bills, too.
Breakfast can be a hot beverage, like coffee or tea, with or without added fat. Lunch and dinners can be a portion of meat or fish with vegetables and a source of fat, and some salt.
Organ meat and the fattiest cuts of meat are often the cheapest ones. Suggest that patients buy what is on special each week at the grocery store, and explore new ways to cook these cuts. There are many cooking videos online for different meat, fish and eggs that can expand the meal repertoire and lower the price. Green vegetables can be purchased frozen —and used as needed without going bad.
Intermittent fasting is quite economical, and the money saved can be reinvested in healthy ingredients, such as fresh vegetables, meat and nuts.