Stop Saying "Ketogenic" When You Mean Low Carb

I’ve received a spate of inquiries from prospective clients recently that start off something like this:

“Hi, Amy, I’m interested in starting a ketogenic diet. Please let me know when we can set up an appointment.”

My initial response to these inquiries is:

“Hi ______,

Thanks for getting in touch. Do you mind if I ask why you’re interested in a ketogenic diet? Do you have a specific medical condition you’re looking to improve? Or if this is for weight loss, what is your current weight, and how much are you looking to lose?”

Once in a while, it’s someone with an autoimmune condition, and I’ve had a couple of inquiries about cancer, but the majority of people I hear from do not require a ketogenic diet. That is, not a classical ketogenic diet.

In case you missed it, there’s been a lot of controversy in the low-carb, keto, and Paleo worlds lately. Some prominent personalities have been sounding the alarm about the potential dangers of ketogenic diets, and in response, hardcore keto loyalists have been firing back. I’m not going to name names here. First, most of you probably already know who I’m referring to, and second, I see no reason to single anyone out, especially when I think there are legitimate arguments on both sides, and in the end, it probably does everybody good to have more information, and make decisions for themselves. (Also, I am the world’s biggest coward one of the least confrontational people around, and I like to keep the peace.)

I really have no skin in this game. I’ve told some clients to eat fewer carbs; I’ve told other clients to eat more carbs. There is no one-size-fits-all approach that works for everyone. If there was, I wouldn’t have clients in the first place, because no one would need my help figuring out why things aren’t working for them. They could read Practical Paleo, go to the grocery store, and be in perfect health and at their ideal weight a few months later.

I’ll let people who enjoy getting involved in pissing contests duke out the details. The issue I want to address in this post is exactly what the title says: stop saying ketogenic when you mean low carb.

When a prospective client reaches out to me, and the only thing I know about them from that first email is that they’re interested in a ketogenic diet, the reason I ask why is because I think people are beginning to use the terms “ketogenic” and “low carb” interchangeably, and they’re not. And I suspect that some of the people writing to me would probably do just fine on a low carb diet (LCD), and don’t have to be so strict as to follow a ketogenic diet (KD).

Let’s clarify the terms here. “LCD” is a fairly nebulous description, but that’s as it should be. Low carb for one person might be 40g of CHO/day, and for someone else, it might be 100-125g/day. That’s a big difference, but they’re both LC, in my book. (Heck, compared to 250g/day, even 150g/day could be considered low!) Plus, this is relative. Are we talking about a 110-pound female, or a 245-pound male? An elite athlete, or someone who doesn’t know a dumbbell from a cowbell? The amount of carbohydrate that might be considered “low carb” could depend on total caloric intake, too. Is someone eating 1700 calories/day, or 3000? As a percentage, 10%, 15%, or 20% of calories from CHO—all of which most of us would consider low carb, at least, compared to the SAD—would translate to very different absolute grams of CHO, depending on the total calories.

The reason I think it’s important to distinguish between LCDs and KDs is, in order to be most effective, a classic KD—as used to manage serious medical conditions—may require certain adjustments that a garden-variety LCD does not.

A standard-type LCD can be considered “ketogenic” in that it can, and often does, produce elevated levels of blood/breath/urine ketones, but a straight-up, no kidding KD requires much more attention to detail than just watching one's carb intake. A true medical-type KD is usually implemented at a 3:1 or 4:1 ratio – that is, 3 or 4 parts fat to 1 part combined carbohydrate and protein. The limitation on protein might be the single biggest difference between a KD and a LCD. There are, of course, many low-carbers who find that they lose weight, maintain weight loss, and just feel better overall when not gorging on protein, but they don’t necessarily have to weigh and measure things to make sure they’re not exceeding some kind of “safe” threshold for protein.

The other big difference, of course, is carbohydrate. There is a gulf of difference between a diet that is upwards of 80% fat and restricted in protein, and one that is 50-65% fat and unrestricted in protein and low-carb vegetables. Someone on a LCD doesn’t have to monitor the carbs in, say, almonds and pistachios, to the extent that someone on a KD might. They don't need to add copious amounts of butter or oil to other foods for the sole purpose of arriving at some magic ratio of fat to protein & carbs.

The degree to which things (might) require micromanaging is another big difference between a LCD and a KD. I am a huge fan of Mark’s Sisson’s philosophy of getting the biggest benefit with the least amount of sacrifice, deprivation, and self-immolation. It’s certainly not impossible to adhere to a KD in the real world, in restaurants, and at social functions, but it’s not exactly easy. A simpler LCD expands the options and takes some of the pressure off. (And the consequences of “cheating” or “treating” or whatever you want to call it, are less severe for someone following a LCD than for someone following a KD specifically to manage an otherwise intractable medical condition.)

Some people need a medically-oriented ketogenic intervention. Some don't. If you don’t, you can still do one. Nobody’s stopping you. But why would you? Why would you choose to eat in such a way that limits the amount of spinach, or cauliflower, or tomatoes, or steak, or lamb you can consume? (Please don’t start in with the animals only/zero carb arguments. Yes, I acknowledge and respect that there are people thriving on diets completely free of plant foods. I will be dedicating a few posts to that in the future. Here, I am talking specifically about people who do not have issues for which no other approach was effective—not Paleo, not low-carb, not SCD, not the autoimmune protocol, and not even keto that included plant matter.) Why would you choose an eating plan that requires close monitoring and micromanaging unless you absolutely had to?

Low carb diets are not necessarily about maintaining blood glucose as low as possible, all the time, as might be the case for cancer, or keeping ketones very high, as might be the case for certain neurological or psychological conditions. Yes, managing blood glucose and insulin levels is a pretty great reason to adopt a LCD, but, barring serious metabolic compromises, that’s usually a happy byproduct of following a good LCD. There’s no need to whip out meters and lancets and log books at every meal or snack. A LCD comes (or should come) without the obsessive compulsion to measure and track all the time, which can lead to some pretty gnarly self-judgment when blood glucose isn’t low “enough,” or ketones aren’t high enough. So many factors play into these things besides just the foods we eat, but people have a tendency to feel like failures if the numbers at any given time aren’t what they were hoping for. (Please note, I’m not saying people shouldn’t track things, especially on true KDs. They probably should. But for regular ol’ LCDs? Sure, maybe at first, for newbies to get an idea of what pancakes do to them, versus a fatty pork chop, but after a while, the LC dieters can loosen up a little more than the keto dieters.)

As for people sounding the alarm about potential pitfalls on KDs, I don’t think they’re entirely out of line. KDs can present risks that standard-type LCDs usually circumvent. But all this means is that the KD should be evaluated for nutrient & electrolyte content, to make sure nothing gets too out of whack, and it might not be a bad idea to try and spread some of the fatty acids out to be accounted for by saturated, mono-, and polyunsaturated fats (including MCTs and omega-3s). Some of the medical-intervention ketogenic diets call for commercially prepared ketogenic-ratio shakes, kind of like Ensure, but specifically formulated for that 4:1 or 3:1 keto ratio, and the fat is predominantly n-6 heavy vegetable oil. I think some of the problems that present with classic KDs are a result of them just being poorly formulated, with absolute garbage substituting for “food.” (i.e. soy protein, casein, soybean oil, corn syrup, maltodextrin, etc.) And, of course, it’s possible, just possible, that some people really do have better health on slightly more carbs. Maybe some of the women (it’s usually women) who claim their thyroid died, or their adrenals tanked, or all sorts of other world-shattering, disastrous, stop-the-presses things happened while super-low-carb, would have absolutely thrived on a diet of 20% or 25% carb, rather than 10%. After all, a diet of 20% carb could be 55% fat and 25% protein, which might not be ketogenic, but most of us would still consider it to be low carb. (For you ultra-purists out there, sure, maybe it’s not super low carb, but it’s certainly low carb compared to the standard American diet, no?)

My guess is that some of the people who claim low-carb killed their thyroid, derailed their menstrual cycle, and all that other stuff, were following very low carb diets while also overtraining, not sleeping enough, having other sources of mental & emotional stress, and very likely, most probably, ding-ding-ding, we have a winner -- not eating enough total calories. Women of all ages, but particularly, young women, tend to fall into this calorie hole. Was it low-carb that derailed their hormones, or was it trying to burn not one candle at both ends, but more like ten candles at three ends (if that’s even possible), while basically starving themselves? Whether or not they were aware of it, that may be what was happening: at a cellular level, they were starving. (Even if they didn't feel especially hungry throughout the day. I’m talking about the cellular level, where we’re not always cognizant of what’s going on.)

YMMV, but I think the majority of folks who are overweight, insulin resistant, diabetic, struggling with PCOS, and more, will see great results by just going low carb. That should be the starting point. A good ol’ LCD, as laid out in the original or 1990s versions of Dr. Atkins' New Diet Revolution, or Protein Power, or the lower-carb options presented in Practical Paleo or The Primal Blueprint. People can fiddle with things from there, if they do not get the results they were hoping for:

In the few diet studies that actually show "success," LC = sufficient for obese IR; full-keto unnecessary for ↓BW. @tednaiman @recomphacks

— Bill Lagakos (@CaloriesProper) July 7, 2015

There are some people who will benefit from going the extra mile and adopting a true ketogenic diet -- or, really, in some cases, just an "ultra low carb" diet, as Kiefer might call it. Aside from the obvious ones (cancer, Alzheimer’s, epilepsy, and other neurological conditions, such as MS and ALS), other conditions that might (might) respond exceptionally well to a ketogenic approach are mood/psychological disorders, the management of which may depend on optimizing brain function and neurotransmitter levels.

Higher carbs, lower carbs, low-carb diets, ketogenic diets, low FODMAPs, low histamines, no plant foods: different tools for different goals. (Not everything is a nail; therefore, we need other tools besides just hammers, capice?)

As for the ongoing mudslinging between the various factions of Paleo, Primal, low carb, and keto, I stand by what I’ve always believed: we agree on so much more than we disagree on. The primary underlying principles of all of these approaches basically overlap: reduce or eliminate grains, refined sugars, processed foods, and vegetable & seed oils; focus on good quality animal foods; don’t fear naturally occurring fat. The rest—FODMAPs, salicylates, the gut biome, whether or not plant foods are essential—is just details. We have enough to debate from the camp that thinks endless acres of corn and soybeans—and the imitation meat products made from them—are the salvation of the entire human race and all the ecosystems on Earth. I’d like to see us stop wasting time and energy fighting among ourselves.

Remember: Amy Berger, M.S., NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition.