7 things you need to know about
alcohol and the keto diet
About six months into his keto journey, however, Clay knew alcohol was causing too much havoc in his life, harming his health and hurting people he loved. He had to stop drinking.
“I realized the way I ate and the way I consumed alcohol were very similar. Once I started I couldn’t stop. It was hard for me to do anything in moderation,” says Clay, 28, who is in the military.
He has been sober now for 2.5 years and on the keto diet for three years (except for 8 weeks in boot camp). He feels wonderful, both because of his diet and his sobriety. He is a lean, muscular 185 lbs (84 kg) and feels fit, strong and clear-headed. He enjoys working out regularly. The cravings for both his trigger foods and for alcohol are gone. He sees the two as being very closely related. And he will not risk, ever, bringing up those cravings again.
“A few potato chips from time-to-time might not kick me out of ketosis, but it could very well awaken the cravings in me… so that saves me from taking the first bite. And I stay away from alcohol entirely. It is not worth taking a single sip, knowing where my mind goes when I drink.”
Alcohol consumption and the keto diet is a hot topic. Many people who want to shed pounds come to ketogenic eating and are delighted that, unlike almost all diets, alcohol is not strictly forbidden when going low carb/high fat. While it may slow weight loss for many people and lower tolerance, the occasional glass of dry white or red wine, champagne, or even distilled liquor is okay — as long as it has no sugar.1
In fact, back in 1964 a slim bestseller called The Drinking Man’s Diet, by Robert Cameron, was one of the first to tout a low-carb diet as a way, in that Mad Men era, to have one’s steak and martini, too. Cut out the sugar and carbs, Cameron said, and moderate alcohol was not a problem.
But is that true for everyone? Well, not exactly. The relationship between sugar, carbs and alcohol, and the caveats around smart consumption when on the ketogenic diet, alas, are not as simple and straightforward as Cameron’s 1960s advice.
For this post, we researched the medical literature and sought the input of an array of experts about alcohol and the low-carb/ketogenic diet. Here are 7 essential points to know:
1. Moderation is key
For those who have healthy livers, not much weight to lose, and no trouble stopping at one drink (for women) or two (for men), the occasional imbibing of a low-carb alcoholic drink is not going to hurt you and may even help with cardiovascular health and joie de vivre.
Dr. Aseem Malholtra, in his new bestselling book The Pioppi Diet2, notes that a glass of wine at dinner among friends and family while eating a low-sugar, no-processed food, Mediterranean diet is part of the recipe for longevity and good health enjoyed by the people living in the Italian village of Pioppi.
Swedish diabetes researcher and medical specialist Dr. Fredrik Nyström, head of internal medicine at Linköping University, has studied dietary intake in various populations and has the same advice for generally healthy people: a daily glass of wine, combined with a low-carb diet, is good for heart health.
Nyström notes that alcohol is actually the fourth macronutrient, after protein, fats and carbohydrates and that in many studies of dietary consumption its intake is often overlooked. In Mediterranean countries like Greece and Italy, alcohol makes up about 10 % of the caloric intake and contributes to the touted benefits of the Mediterranean diet, Nyström says. “Alcohol is found to lower blood pressure and to acutely lower blood glucose. These effects are very well proven. It tends to increase healthy HDL cholesterol and it lowered LDL cholesterol in one of the studies I conducted.”3 Drinking alcohol, however, can slow weight loss for some. Dr. Sarah Hallberg advises her patients, who are trying to lose weight and/or reverse diabetes, to have a maximum 1 glass of wine for women and 2 for men, and not every day. “If they experience any weight stall, I recommend they stop the alcohol completely,” says Hallberg.
Both Dr. Jason Fung and Dr. Ted Naiman discourage any alcohol use among patients in their care who are still trying to lose weight, reverse diabetes or heal a fatty liver (see point 5). “I find alcohol is not conducive to steady weight loss,” said Fung.
Keto expert Maria Emmerich notes that the reason alcohol slows weight loss is not because of its calories, but because it stops the body’s ability to utilize fat stores for energy. Fat metabolism is reduced by 73% after only two low-carb alcoholic beverages, she says.4
The takeaway: small amounts of low-carb alcohol are fine, but if your weight loss stalls or you still have issues of metabolic health, consider abstaining, at least for now.
2. Moderate drinkers: fundamentally different?
Many studies have shown that alcohol consumption when graphed against mortality risk is a J-shaped curve. Abstainers have slightly higher mortality risks than moderate drinkers and heavy drinkers have the highest risks of all. (Debate has raged whether the teetotalers group includes former heavy drinkers now abstaining, hence the worse result.)5
Gary Taubes, in a discussion hosted by the New York Times says he is suspicious of these sorts of epidemiologic findings: “The question I always had about these studies was whether or not people who drink alcohol in moderation are just different than the teetotalers, who drink none, and the binge drinkers, who drink to excess. Maybe by looking at a glass or two of alcohol a day you’re selecting out for people who live their entire lives in moderation, people capable of living well without excess.”6
Nora Gedgaudas, author of Primal Body Primal Mind notes that those who drink heavily, especially alcoholics who cannot control their drinking, have problems with blood-sugar regulation relating to severe carbohydrate addiction. They are seeking fast sources of sugar to the brain, of which alcohol provides the fastest source. She likens it to throwing gasoline on a fire.7
The takeaway: Be honest with yourself. Can you easily stop at one or two drinks max? If you can’t, our experts say be very cautious with alcohol and consider abstaining. Naiman notes that at higher levels of consumption, alcohol is highly toxic to multiple organ systems, and linked to hypertension, gout, nerve damage, cancers and cognitive decline.
3. Can’t easily stop? It’s your brain chemistry
Many people who have trouble moderating their eating or drinking often beat themselves up. Clay describes his feelings of self-hatred for his once uncontrolled eating and drinking. But as Diet Doctor sugar-addiction expert Bitten Jonsson stresses, the inability to quell cravings and moderate one’s consumption — whether high carb foods or alcohol — has nothing to do with will power and everything to do with the altered biochemistry of the brain.8
“The brain chemistry that drives the addict to seek pleasure beyond the point of satiety is similar, whether the user favours Jack Daniels or Jack-in-the-Box,” says Dr. Vera Tarman, author of Food Junkies, a book that Jonsson recommends for all sugar addicts.
Dr. Robert Lustig agrees and notes that neuroscience and addiction research shows that the brain’s dopamine (reward system) pathway is the same whether it is sugar, alcohol, nicotine, cocaine, porn, gambling… whatever. “All hedonic (pleasure-causing) substances and all hedonic behaviors work through the exact same dopamine pathway. All of them,” says Lustig, the best-selling author, anti-sugar advocate and pediatric endocrinologist. In his latest book The Hacking of the American Mind, Lustig describes how big businesses, like the sugar industry, beer companies, processed food manufacturers — even social media apps and smart phones — knowingly exploit this dopamine pathway to drive profits and to keep us coming back for more, despite detriments to our health and wellness.
Even if you are able to successfully stop one addiction, addiction transfer, also called addiction-interaction disorder, is a well known phenomenon. Jonsson notes that many sugar addicts can become alcoholics. Likewise, alcoholics who quit drinking often turn to sugar in an attempt to control cravings. Studies show that patients undergoing bariatric surgery, who can no longer overeat, have a 20 % higher rate of post operative problems with alcohol dependence.9
“When you are addicted to one substance and find yourself abstaining, your dopamine’s modus operandi is to find a substitute trigger,” said Lustig.
The takeaway: if you are doing the low-carb keto diet to help deal with a disordered or addictive relationship to carbs or sugar, addiction transfer to alcohol may occur. Our experts recommend abstaining.
4. An adaptive trait that helped, now harms
Our innate dopamine reward system, which says “this is good, I want more” was likely a highly functional trait for survival in our primate and hunter-gather days, but our stone-age genes have not adapted to the modern world.10
The evolutionary studies of why our brain biochemistry may spur some to overeat or drink to excess are fascinating and varied, but almost all have to do with the ancient need to spur over-consumption of high-calorie fruit and carbs in season in order to pack on the fat to live off of during lean seasons and food shortages.11
In 2014 researchers in Florida sequenced human and primate genomes and worked backward to find the common ancestor 10 million years ago that first began to efficiently metabolize ethanol (fruit alcohol) found in fermenting fruit lying on the forest floor. A genetic mutation was found that linked to a time when primates were coming down out of trees, the earth was cooling off, and food sources were changing. Primates who had the mutation could eat the fermenting fruit on the ground in the limited time it was available, metabolize the ethanol 40 times more successfully, get the extra calories and thrive. The researchers hypothesized that hominid brains then evolved to link its pleasure pathways to alcohol consumption because it was associated to finding and consuming a key high-calorie food source in season.12
The takeaway: some people find more self-acceptance — and a better ability to understand and control their cravings — by knowing about a once-helpful ancient trait, like over-consuming alcohol, that in modern times is a liability. As Lady Gaga sings in her anthem to self acceptance: “Rejoice and love yourself today; Cause baby you were born this way.” As you can’t change your biology, avoid the trigger — alcohol — and prevent the overconsumption.
5. Fatty liver? Lay off the booze until it heals
As a number of recent Diet Doctor posts have noted, non-alcoholic fatty liver disease (NAFLD) is a huge health epidemic, impacting increasing numbers world wide — including 65 million people in the US alone. It is largely caused by overconsumption of fructose and low-fat foods. Dr Evelyne Bourdua-Roy wrote about how common NAFLD is among the patients in her GP practice — but also how reversible it is on a low-carb, low-fructose, high-fat, no-alcohol diet.13 Lustig notes that fruit sugar — fructose — and alcohol, unlike glucose, go straight to the liver where they are metabolized almost exactly the same way. “Fructose is alcohol without the buzz,” says Lustig. Ethanol and fructose are metabolic cousins and both promote fatty liver, leading to eventual liver fibrosis, scarring and potentially cirrhosis, liver failure and even liver cancer.14
Higher rates of non-alcoholic fatty liver disease (NAFLD) are very common in people with diabetes, obesity, and polycystic ovarian syndrome. On a scan, a fatty liver looks exactly the same whether caused by chronic alcohol consumption or high-fructose intake in someone who has never touched a drink.15
The takeaway: Anyone with any fatty or fibrotic liver issues should avoid sugar, carbs and alcohol until the liver has healed. “If you have liver problems you should avoid alcohol under all circumstances,” says Lustig.
6. Lower tolerance, worse hangovers
Many people posting in forums and discussion groups about the ketogenic diet report that their alcohol tolerance is much lower, and their hangovers much worse on a low-carb diet. While there is not a lot of scientific research yet to explain why tolerance is lowered, one of theories is that when drinking alcohol the brain uses less glucose and more acetone for energy, one of the ketones. When you are already running on ketones, consuming no carbs, your only glucose is from gluconeogenesis.16
When you consume alcohol, the liver might prioritize gluconeogenesis or ketone formation rather than ethanol metabolism – increasing the effect of alcohol. As well, a stomach full of carbs will slow down alcohol absorption, but many people eat much less on the keto diet. Be careful, you will become intoxicated at lower levels of alcohol consumption. Especially don’t drink and drive. (And note: even if you have not drunk very much, ketones in your breath may make you blow over in a breathalyzer, as some case reports have noted.)17
Worse hangovers are likely the result of dehydration, electrolyte imbalances and hypoglycemia. Carbs hold onto water where as the ketogenic diet increases urination and fluid loss. Alternate water between any alcoholic drinks and consider adding some salt and taking magnesium and potassium supplements.
Alcohol is known to lower blood glucose because the liver is busy metabolizing the ethanol and not making more glucose through gluconeogenesis.Here is another important caution: for those doing the keto diet and intermittent fasting, a sudden episode of heavy binge drinking could even predispose some individuals to the dangerous situation of alcoholic ketoacidosis, in which ketones are very high in the blood, but unlike diabetic ketoacidosis, blood glucose is dangerously low. “Theoretically, there would be an increased risk of alcoholic ketoacidosis if binge drinking and fasting,” said Dr. Fung.18
The takeway: Be careful. Alcohol and its harms are much more potent on a ketogenic diet. See point 1: Moderation is key.
7. The keto diet can reduce alcohol cravings and may even help curb alcoholism
Many people, like Clay, have found the keto diet greatly helped reduce their cravings for both sugar and alcohol and reduced their urge and need to drink — likely because the diet evens out blood sugar fluctuations. Discussion threads on the popular social media site Reddit have many posts from people who found adopting the ketogenic diet helped them lower their consumption or even kick their alcohol addiction.19
“Once you get past the carb addiction and become a fat burner, your body has that other fuel (fat) that it can use instead of carbs and ethanol, and because it’s so satiating, both the carb and ethanol cravings subside, ” said “Rockithound” on the Reddit discussion.20
Film director Tom Naughton, who made the documentary Fat Head, says that when he was a vegetarian he craved alcohol and had trouble stopping once he started drinking. He lost the craving and desire to drink when he went on the low-carb/high-fat diet. “I thought I needed a 12-step program. Turns out I actually needed a medium-rare steak.”21
The ketogenic diet may even help alcoholics detox. The US National Institute on Alcohol Abuse and Alcoholism in Bethesda, Maryland is currently starting a new clinical trial to investigate the use of the ketogenic diet during detox for alcohol dependency. Principal investigator Corinde Wiers, PhD, notes that a number of studies and observations on brain energetics suggest that the ketogenic diet is a promising supplementary intervention for alcohol use disorders (AUD.)22
The NIAAA team is now recruiting 50 initial subjects, male and female, who are dependent on alcohol and want to stop drinking. These people will be admitted for an all-expenses paid residential treatment program for alcoholism for three weeks and randomized into the ketogenic diet (25 people) and the standard American diet (25) while undergoing otherwise normal detox therapy. Then after discharge, the patients will be followed for a year to assess drinking behaviour and relapses, if any.“We will test if the ketogenic diet has an effect on withdrawal symptoms, craving, alcohol cue-induced brain reactivity and sleep quality,” says Wiers. If it does, then the ketogenic diet could become part of the arsenal of therapy for alcoholics who want to quit, she says.
The takeaway: the ketogenic diet could help you reduce your cravings for alcoholic drinks, or even help you quit altogether.
In short, drink moderately and stop if weight loss stalls. Be careful how alcohol triggers your own cravings for overconsumption. Watch out for lower tolerance and other harmful effects of mixing alcohol with keto (especially if you have fatty liver disease), and potentially note the positive impact on cravings on keto. Finally, of course, never drink and drive.
For Clay, he is happy that more people are talking about the ketogenic diet and alcohol. “I wish I had known about it earlier.”
What has been your experience with alcohol and the keto diet? Tell us in the comments below. And if you want to know more about what alcoholic drinks are low-carb or keto, check out our low-carb alcohol guide.
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Wiers list of studies and observations:
1.Volkow ND, Wiers CE, Shokri-Kojori E, Tomasi D, Wang GJ, Baler R. Neurochemical and metabolic effects of acute and chronic alcohol in the human brain: Studies with positron emission tomography. Neuropharmacology 2017; 122: 175-188.
2.Volkow ND, Kim SW, Wang GJ, Alexoff D, Logan J, Muench L et al. Acute alcohol intoxication decreases glucose metabolism but increases acetate uptake in the human brain. NeuroImage 2013; 64: 277-283.
3. Jiang L, Gulanski BI, De Feyter HM, Weinzimer SA, Pittman B, Guidone E et al. Increased brain uptake and oxidation of acetate in heavy drinkers. The Journal of clinical investigation 2013; 123(4): 1605-1614.
4. Wang J, Du H, Jiang L, Ma X, de Graaf RA, Behar KL et al. Oxidation of ethanol in the rat brain and effects associated with chronic ethanol exposure. Proceedings of the National Academy of Sciences of the United States of America 2013; 110(35): 14444-14449.
5. Martin K, Jackson CF, Levy RG, Cooper PN. Ketogenic diet and other dietary treatments for epilepsy. The Cochrane database of systematic reviews 2016; 2: CD001903.
6. Cervenka MC, Hocker S, Koenig M, Bar B, Henry-Barron B, Kossoff EH et al. Phase I/II multicenter ketogenic diet study for adult superrefractory status epilepticus. Neurology 2017; 88(10): 938-943.
7. Derr RF, Draves K, Derr M. Abatement by acetate of an ethanol withdrawal syndrome. Life sciences 1981; 29(17): 1787-1790.