Today’s focus is on: Ten Defining Characteristics of a Well-Formulated Ketogenic Diet by Stephen Phinney, MD, PhD, Jeff Volek, PhD, RD
To promote a better understanding of what constitutes a well-formulated ketogenic diet, we have identified 10 key characteristics:
- Sustains nutritional ketosis
- Maintains or improves lean body mass and performance
- Effective electrolyte, mineral and hydration management
- Fat provides majority of dietary energy in all phases
- Counting calories is not necessary for success
- Totally or predominantly composed of ‘whole foods’
- Short-term very low-calorie diets should be avoided until proven effective in long term studies
- Contraindicated for chronic conditions unless a credible long-term maintenance phase has been demonstrated
- On going expert medical supervision required for medication management of chronic conditions (e.g., type 2 diabetes, hypertension)
- A well-formulated ketogenic diet does not necessarily adhere to traditional dietary guidelines
Note: This Post contains the first 5 characteristics. The remaining 5 will follow next week.
The short and long-term health benefits of nutritional ketosis (NK) include a reduction in hunger and cravings, reduced inflammation and improved insulin sensitivity. These benefits of NK predictably lead to improved metabolic health and major weight loss.
A thorough understanding of the proper composition and management of a well-formulated ketogenic diet (WFKD) is essential in order to achieve and sustain the benefits of nutritional ketosis. In the short-term, appropriate fluid and electrolyte/mineral intakes that match the unique requirements associated with keto-adaptation are necessary for optimum well-being and can markedly reduce or prevent symptoms of the so-called ‘keto-flu’. Getting and keeping this formulation ‘right’ for the individual is necessary to optimize and sustain metabolic health, disease reversal (e.g., type 2 diabetes, metabolic syndrome, hypertension), and major weight loss.
It is also important to keep in mind that for individuals who start out taking medication for a major disease like type 2 diabetes and/or hypertension, a WFKD is a powerful medical therapy which necessitates day-by-day medication management by an expert physician and team to prevent dangerous drug side-effects. We strongly recommend getting medical supervision before making any dietary changes, especially if you are on medications for blood sugar or blood pressure. A physician can help you safely adjust your medications so that they don’t drive your blood sugar or blood pressure too low. Both hypoglycemic (low blood sugar) and hypotensive (low blood pressure) episodes can be very dangerous.
Here are 10 necessary basic components to optimize the benefits of nutritional ketosis and to avoid the common pitfalls.
Defining Characteristic #1: A WFKD must result in sustained nutritional ketosis.
- Due to individual variations in carbohydrate tolerance, total daily carb intake can range from nearly 0 to 70 g/d.
- Since beta-hydroxybutyrate (BOHB) functions as both a fuel and regulatory signal, we have defined nutritional ketosis as an average serum BOHB concentration in the range between 0.5 mM and 4.0 mM as measured by a finger stick glucometer with a ketone testing.
- Despite its reduced carbohydrate content, food needs to be tastefully prepared with adequate variety so as to be palatable and sustainable.
Defining Characteristic #2: A WFKD has to provide adequate macronutrients to preserve lean body mass and function.
- Effective protein intakes can range from 1.2 to 2.0 g/kg-d reference weight, where reference weight is based upon sex-based standard values for height. See my Blog 2healthyhabits for Dr. Phinney’s protein recommendations https://2healthyhabits.wordpress.com/2018/11/09/how-much-protein-do-you-need-in-nutritional-ketosis/
- In this protein dose range, the addition of dietary carbohydrate is not necessary to maintain lean body mass.
- The combination of both carbohydrate and protein intakes at the upper ends of an individual’s tolerance range typically drives ketones down out of the NK range, particularly for those with underlying insulin resistance. For this reason, the best practice of a WFKD typically requires holding protein in moderation and adding just enough dietary carbohydrate to allow dietary variety and provide valuable micro-nutrients and minerals from vegetables, nuts/seeds, and berry fruit.
Defining Characteristic #3: A WFKD contains enough electrolytes and intercellular minerals to maintain optimum circulatory, muscle, and nerve functions.
- Adequate sodium and potassium are provided to support circulatory volume and avoid potassium depletion resulting in impaired muscle anabolism (building up process)or adrenal stress.
- Accelerated renal sodium excretion associated with nutritional ketosis raises the typical adult daily sodium intake requirement to 4 – 5 g/d with exceptions for those taking medications for hypertension or congestive heart failure.
- Magnesium depletion signs/symptoms such as muscle cramps, muscle fasciculations (flicker under the skin),and persistent hypokalemia (deficiency of potassium)are common in adults due to poor dietary intake combined with medication and/or alcohol effects on renal excretion.
- Magnesium intake often needs to be increased by food choices or supplementation to normalize neuromuscular and cardiac functions as well as lean body mass preservation independent of dietary protein adequacy.
Defining Characteristic #4: In all phases of a WFKD, the majority of daily energy intake will come from dietary fat.
Induction = 80-120 g/d protein, 30-50 g/d carb, 60-100 g/d fat
Maintenance = 80-120 g/d protein, 30-70 g/d carb, 100-200 g/d fat
- In all phases, the majority of fat needs to come from mono-unsaturated and saturated sources from the foods themselves or as added natural fats.
- Adequate omega-6 essential fats are obtained from whole food vegetable and animal/vegetable protein sources. Omega-6 rich vegetable oil sources should be routinely avoided whenever possible.
- As weight loss stabilizes and glycemic control typically improves over the first year of a well-formulated ketogenic diet, it may be possible to add a small amount of additional (unprocessed)carbohydrates back into the diet while still maintaining nutritional ketosis.
- Protein remains relatively constant over this time, while fat intake may increase to meet caloric needs.
This graph, Daily caloric intake and expenditure, illustrates a typical physiological weight loss response to a well-formulated ketogenic diet eaten to satiety rather than when prescribed as a rigid caloric restriction. Note that in this scenario, dietary protein is moderate and unchanged, carbohydrate is held constant or only slightly increased in a narrow range, and one’s spontaneous intake of fat increases to sustain satiety as major weight loss transitions into weight maintenance.
In insulin resistant adults, carbs are initially limited to 30 grams per day, then liberalized slowly while maintaining ketosis.
Daily protein prescribed in a range between 1.2 and 2.0g/kg reference weight (approx. 15% daily expenditure). Fat is consumed to satiety.
Defining Characteristic #5: Counting or restricting calories is not necessary for lasting success.
- While many “diets” restrict calories in order to get results, a well-formulated ketogenic diet allows the individual to eat fat to satiety and still lose weight and improve metabolic health.
- Calorie counting is not essential; however, individuals must be mindful not to eat past satiety or purposefully consume fats in excess of energy needs in an effort to increase ketone values.
- For many people who have spent a lifetime eating a fat-restricted diet, which promotes inflammation and inhibits satiety, experiencing the prompt sense of having eaten enough (i.e., satiety, not fullness) that occurs with nutritional ketosis can be a new experience.
Note: This Post contains the first 5 characteristics. The remaining 5 will follow next week.
SOURCE: The Ten Defining Characteristics of a Well-Formulated Ketogenic Diet
Stephen Phinney, MD, PhD, Jeff Volek, PhD, RD on August 13, 2018. This post has been condensed from the original Virta Post.
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