Nutritional Ketosis and Ketogenic Diet FAQ

Written by Dr. Stephen Phinney and the Virta Team

Nutritional ketosis is a natural metabolic state in which your body adapts to burning fat rather than carbohydrates as its primary fuel. It is clinically proven to directly reduce blood sugar (as measured by HbA1c), improve insulin sensitivity (as measured by HOMA-IR) and reduce inflammation (as measured by white blood cell count and CRP). Nutritional ketosis can be induced by following a ketogenic diet. Learn more in our FAQ below!

Learn more about Virta’s diabetes reversal treatment here.


All About Ketosis

What is nutritional ketosis?

Nutritional ketosis is a natural metabolic state in which your body is fueled mainly by fats and ketones, instead of carbohydrates (glucose).
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How do I get into nutritional ketosis?

Nutritional ketosis happens when dietary carbohydrates are significantly reduced (<50 grams per day) and the body’s production of ketones increases to maintain a blood level at or above 0.5 mM.
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How can I tell if I’m in nutritional ketosis?

Ketone production in the body is a very natural process that can be measured at home by a medical device such as the Precision Xtra meter or KetoMoJo meter.
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What are ketones? What is ketogenesis?

When we say ketones, we are referring to the primary circulating fatty acid metabolites beta-hydroxybutyrate (βOHB) and acetoacetate (AcAc)
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What is keto-adaptation?

When maintained for several consecutive weeks, nutritional ketosis fundamentally changes the way cells work.
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What does it mean to be fat adapted?

This term is often used synonymously with keto-adaptation, and commonly used to describe low-carb adapted athletes.
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Ketogenic Diets

What is a ketogenic diet?

A ketogenic diet that is restricted in carbs and moderate in protein results in increased production of ketones.
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What can I eat on a ketogenic diet?

There are plenty of delicious high-fat, low-carb options available, and you can eat out or cook at home.
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Why is sugar bad for you?

When you consume sugar or carbohydrates (which get absorbed as blood sugar), this triggers an insulin response by your body.
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How many carbs can I eat on a ketogenic diet?

Carbohydrate tolerance varies among individuals.
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Should I count net carbs or total carbs?

On Virta, we recommend counting total carbohydrates, with the most of your food coming from real, whole foods.
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Is a ketogenic diet healthy for everyone, not just people with diabetes or weight issues?

We humans are a very diverse lot, and there is no known diet that is perfect for everyone.
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What is “keto flu” and how do I avoid it?

The ”flu-like” symptoms that some individuals experience when starting the ketogenic diet is due to the body’s response to carb restriction.
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Should I take vitamins or supplements on a ketogenic diet?

It is well known that whole foods should be emphasized over dietary supplements because essential vitamins and minerals found in foods are usually better absorbed than those found in supplements.
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How much sodium, potassium and magnesium should I have on a ketogenic diet?

In short, 3000-5000 mg of sodium and 2000-3000 mg of potassium on average are needed as part of a well-formulated ketogenic diet.
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How much protein should I eat on a ketogenic diet?

Most healthy humans maintain lean body mass and function during a ketogenic diet providing between 1.5 and 1.75 grams of protein per kg of ‘reference body weight.’
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What are the best artificial sweeteners and sugar substitutes for a ketogenic diet?

Xylitol is among the better choices because it is a dental protectant, and because it provides usable energy.
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Can I be vegetarian and still do nutritional ketosis?

Absolutely! While 10-20% of your daily energy need should be coming from protein, you can meet this need by consuming high protein, vegetarian and keto friendly foods.
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Can I be vegan and still do nutritional ketosis?

Achieving nutritional ketosis while being a vegan is possible but this style of eating will be restrictive and require a large amount of pre-planning.
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Can I eat dairy on a ketogenic diet?

There is no need for people to avoid dairy products unless they have specific symptoms brought on by their consumption (e.g., lactose intolerance).
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Can I eat gluten on a ketogenic diet?

A ketogenic diet is naturally very low in gluten, but if you do not have gluten intolerance or celiac disease, there is no need to avoid gluten.
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Do I need to eat vegetables on a ketogenic diet?

In addition to getting fiber, there are many other reasons to consume vegetables.
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Do I need fiber supplements on a ketogenic diet?

There are clear benefits from fiber consumption for bowel function and blood sugar control in people consuming a diet high in carbohydrates.
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Can I eat whey protein on a ketogenic diet?

Whey protein is a double-edged sword: it has a very high biological value score, but it also causes higher insulin secretion.
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What can I eat at a Chinese restaurant on a ketogenic diet?

You can ask for steamed versions of some dishes and then add soy sauce, which fits within the guidelines of a well-formulated ketogenic diet.
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Ketogenic Diets and Diabetes

Can a ketogenic diet reverse type 2 diabetes?

Insulin resistance is the hallmark of type 2 diabetes and manifests as carbohydrate intolerance.
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Does a ketogenic diet reduce insulin resistance?

Insulin resistance improves promptly for most people when they begin a ketogenic diet, and the effect appears to be attributable to the ketones.
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Can I reverse diabetic neuropathy, nephropathy, or retinopathy with a ketogenic diet?

We have many anecdotes of reversal of neuropathy, retinopathy, and nephropathy in people with T2D following a well-formulated ketogenic diet.
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Ketosis vs. Ketoacidosis: What’s the difference?

In contrast to this normal physiology of ketosis, pathologic ketoacidosis manifests with serum levels ketone levels of 15-25 mM (three- to ten-fold higher than in nutritional ketosis).
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Heart health and cholesterol

Is a ketogenic diet safe for your heart?

In the context of a well-formulated ketogenic diet (high fat, low carb, moderate protein), the intake of fat is not only safe, but imperative for long-term success.
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What happens to your cholesterol on a ketogenic diet?

For most people, a ketogenic diet leads to improvements in cholesterol, but there are sometimes transient rises in cholesterol levels during weight loss.
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What happens to LDL cholesterol on a ketogenic diet?

A ketogenic diet typically leads to a broad range of improvements in blood lipids as well as other cardiovascular risk factors such as blood pressure and inflammation.
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What happens to triglyceride levels on a ketogenic diet?

Triglycerides are among one of the most predictable changes when one adapts to and maintains a well-formulated ketogenic diet.
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Do statins decrease the production of ketones?

There are no known problems associated with combining statin use with a well-formulated ketogenic diet.
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Safety on a Ketogenic Diet

Is nutritional ketosis safe?

Nutritional ketosis, achieved by following a well-formulated ketogenic diet is a safe and beneficial metabolic state for most people.
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What is ketoacidosis?

This is a distinct pathologic state that happens when insulin levels are extremely low, such as in a person with type 1 diabetes who cannot produce insulin.
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Is it safe to increase salt intake on a ketogenic diet?

In the setting of a well formulated ketogenic diet, a modest increase in salt intake is safe, and does not raise blood pressure (Hallberg 2018).
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Is it safe to follow a ketogenic diet during pregnancy?

This is an excellent question for which there is no solid scientific answer.
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Is it safe to follow a ketogenic diet while breastfeeding?

While there are many anecdotes of women nursing while following a ketogenic diet, there are no published large prospective studies demonstrating safety and effectiveness of this practice.
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Is it safe to follow a ketogenic diet if you have no gallbladder?

The gallbladder is a storage organ for bile, which (among other functions) helps with the digestion of dietary fat.
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Can I follow a ketogenic diet if I have no thyroid?

In general terms, taking thyroid medication can fully replace what the thyroid gland normally does.
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Can a ketogenic diet help with Lyme disease?

The topic of Lyme disease is very complex, involving both an infectious cause and often a prolonged inflammatory response after the infection is eradicated.
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How does a ketogenic diet affect kidney stones?

Our clinical experience is that kidney stones are rare during a well-formulated ketogenic diet.
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Does a ketogenic diet increase your risk of gout?

There is a short-term increased risk of gout flares when initially entering into nutritional ketosis due to the competitive inhibition of ketones on kidney excretion of uric acid.
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Is fasting safe?

Any regimen involving fasting beyond 24-hours has not been proven effective in sustaining weight loss long term.
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Weight loss on Ketogenic Diets

Does a ketogenic diet cause weight loss?

Being in nutritional ketosis will accelerate the rate at which the body burns fat, and this is a fundamental key to the short- and long-term benefits of a ketogenic diet.
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How do I break a weight loss plateau on a ketogenic diet?

There are small dietary changes you could consider, which may help push past a true weight plateau.
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Is dietary fat burned before stored fat on a ketogenic diet?

For regular dietary fats, once they are digested, they enter the circulation and participate in what is called ‘fatty acid turnover’.
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How can I lose belly fat on a ketogenic diet?

Losing central fat (belly fat) is one of the many benefits of a well-formulated ketogenic diet.
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Troubleshooting a Ketogenic Diet

What causes muscle cramps on a ketogenic diet?

Cramps may occur for a variety of reasons. A mineral imbalance may manifest in physical symptoms like cramps and is often resolved by magnesium supplementation
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What do I do if I get diarrhea on a ketogenic diet?

Diarrhea is not a common side effect of a well-formulated ketogenic diet. If it occurs, it likely due to well-intentioned but incorrect food choices.
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How do I fix constipation on a ketogenic diet?

Many people assume that constipation while following a well-formulated ketogenic diet is due to inadequate fiber.
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Does keto cause hair loss?

Hair loss is not commonly seen with a well-formulated ketogenic diet. Here are a few causes of hair loss.
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What causes keto rash and how do you fix it?

In our experience, ‘keto rash’ is relatively rare. In the cases we’ve seen, it tends to occur early in the course of a ketogenic diet.
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Why do ketone levels vary throughout the day?

Individuals vary in their blood ketone levels (i.e., beta-hydroxybutyrate – aka BOHB) over the course of a day and from day to day.
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What are the consequences of cheating or lapsing on a ketogenic diet?

Intermittent breaks in adherence to ketogenic diets has not been studied carefully in humans.
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How should I interpret and apply CGM data?

The use of continuous glucose monitors (CGM) serves a variety of purposes and depends on the individual.
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Fats and Oils on a Ketogenic Diet

Which fats and oils should I eat on a ketogenic diet?

On a well-formulated ketogenic diet where 70-80% of your daily energy comes from fat, the majority of your dietary fat should be from sources of monounsaturates and saturates.
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Can I eat canola oil on a ketogenic diet?

Sources of saturated and monounsaturated fats should provide the majority of your dietary fat intake.
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What is the best ratio of MUFA, SFA and PUFA on a ketogenic diet?

In general, people don’t tolerate high amounts of polyunsaturated fats (PUFAs) as part of a high fat diet.
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Can I use olive oil as a cooking oil?

Every oil or fat has a temperature range within which it performs best and a point at which it begins to breakdown (smoke point).
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Is fat the most satiating macronutrient?

Satiety is very subjective, so it’s hard to measure it precisely
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Related blog posts

Dr. Stephen Phinney on Nutritional Ketosis and Ketogenic Diets: Video Series - Dr. Stephen Phinney put together a three-part video series on ketogenic diets and nutritional ketosis. You'll learn the nutrition science… ... Read More
Ketone Supplements: The Pros and Cons - Ketone supplements rapidly and transiently increase blood concentrations of BOHB. On the surface, this seems like it should promote positive… ... Read More
Sarah Hallberg, DO, MS Reversing Diabetes 101 with Dr. Sarah Hallberg: The Truth About Carbs, Blood Sugar and Reversing Type 2 Diabetes - You may have heard a lot about type 2 diabetes, but do you know what it actually does to your… ... Read More

44 Comments

  1. Avatar

    Is there a list of published research on the ketogenic diet that you can share? I’d like to see what the science says.

    Reply

    1. Avatar

      You would be better off doing your own research. I recently did a presentation on the keto diet in relation to diabetes management and the recent data is inconclusive. One study will show a positive result and another will show no difference between the US dietary guidelines and the keto diet. Then other studies will show adverse effects on the keto diet. One thing they all have in common is there is no long term studies to support the keto diet which is concerning.

      Reply

      1. Virta Health

        Annie, You should check out our latest publication from our ongoing clinical trial that was published last week. It demonstrates the results of the Virta Treatment at 2 years from our clinical trial participants: https://www.virtahealth.com/research

        Reply

  2. Avatar

    Lots of bad information out there about ketogenic diets. Glad to have this resource! I’ve read The Art and Science of Low Carbohydrate Living too, but it’s way easier to search for topics here than reading a whole book.

    Reply

  3. Avatar

    Love Stephen Phinney! I found Virta’s youtube channel recently. Lots of good stuff on diabetes and ketogenic diets. And plenty of other speakers I love too – Phinney, Volek, Hallberg. Taubes, etc.

    Reply

  4. Avatar

    Would highly recommend listening to Tim Noakes and his trail in Cape Town – he was pretty much the trigger for me to switch to LCHF and now I am starting to educate myself on what I need to follow a path that works for me. The information on Verta is giving me more information to enable me to ask my Dr for what I want – I know this will be an uphill battle and this information will help me avoid getting railroaded into the so called norms. It also give the Dr a way out because then I am asking him to help me go down a certain path that he is not responsible for recommending if it bucks the system.

    Reply

  5. Avatar

    Does Medicaid cover the Virta program?

    Reply

    1. Virta Health

      At this time, it does not. But, keep an eye on us as we hope to have increased insurance reimbursement in the future!

      Reply

  6. Avatar

    Does Virta have information about keto and health of the liver? Particularly fatty liver disease? Thank you.

    Reply

    1. Virta Health

      Stay tuned as we have more information coming out on that soon!

      Reply

  7. Avatar

    How do I find a.doctor in my area to guide me through this process?

    Reply

    1. Virta Health

      Virta is available across the US via telemedicine. To learn more, head to https://www.virtahealth.com/thevirtatreatment to learn more about how it works.

      Reply

  8. Avatar

    I have a question
    Say u r doing the keto diet and ur blood sugar drops to 63. What should u eat so as not to go in a coma nor get ur carb count over 30! I only eat fish too! Help? This has happened to me twice in the last week.

    Reply

    1. Virta Health

      We are unable to provide specific medical advice via this forum. The response will also differ if you are taking blood sugar lowering medications versus not. We would encourage you to find a provider in your area or look into the Virta Treatment as an option at https://www.virtahealth.com/thevirtatreatment

      Reply

  9. Avatar

    Ketosis has great fat burning properties but can you achieve this as well as gaining lean body mass? And do you need to be in a calorie surplus or deficit to do so?

    Reply

  10. Avatar

    Ketosis is clearly great for fat loss but is it possible to gain lean mass at the same time? Do you need to be in a calorie deficit or surplus?

    Reply

    1. Virta Health

      Typically, to gain lean body mass one needs to have some degree of caloric surplus, or at the very least, not be in a significant deficit. This is especially true when looking to add muscle mass. It is certainly possible to gain muscle mass on a ketogenic diet. For most individuals this would require consuming adequate protein (while still remaining in ketosis), enough calories to support growth, sufficient electrolytes to support muscle function, as well as incorporating progressive resistance training. The type and volume of resistance exercise needed to add lean body mass will be very dependent on the individual and their age, training status, health status, etc. Therefore, the answer to this question can become quite nuanced, but in simple terms, yes, it is very possible to gain lean body mass on a ketogenic diet while still taking advantage of the health promoting effects this way of eating provides.

      Wilson et al. The Effects of Ketogenic Dieting on Body Composition, Strength, Power, and Hormonal Profiles in Resistance Training Males. J Strength Cond Research. 2017. DOI: 10.1519/JSC.0000000000001935

      Reply

  11. Avatar

    Hello, may I ask if someone has some experience week fasting for 14 days? I was told that the food which should be started taken after 14 days of fasting has to be in very simple and in slow amount. Unfortunately 1-2 days after fasting I am allowed to take only bouillon out of buckwheat, barley, from the 3rd day buckwheat mush, and only from 5th day milk or sour cream, oil since 11th day. Can anyone advice how should I adopt this come back food path to Ketogenic diet? Thank you in advance, Maria

    Reply

  12. Avatar

    Hello,

    Is it alright for the ketone levels to drop after any type of exercise (bike ride or strength training). Is this a phase where my body is still not fully fat adapted and it burning glycogen during the exercise which causing the ketone levels to drop?

    Reply

    1. Virta Health

      Hi Imran! Great question. Dr. Phinney has previously written on this topic here: https://blog.virtahealth.com/why-ketone-levels-vary/

      “Individuals vary in their blood ketone levels (i.e., beta-hydroxybutyrate – aka BOHB) over the course of a day and from day to day. This can be due to variations in dietary carbohydrate and protein from meal to meal and from day to day…Additional factors that increase blood BOHB are endurance exercise and also after consuming fats containing medium chain triglycerides (MCT) such as butter, coconut oil, or purified MCT oil. In contrast, there is often a steep drop in BOHB after high intensity exercise, the mechanism for which has yet to be proven. This post-sprint drop in BOHB tends to be temporary (lasting for an hour or two), which means that it’s cause is very different from the days-long drop in blood BOHB that one sees after a large carb meal.”

      Reply

  13. Avatar

    is licorice okay to have on a ketoic diet

    Reply

    1. Virta Health

      Licorice will have too many carbohydrates.

      Reply

  14. Avatar

    Is there any way to determine electrolyte needs if you are a long distance runner? I read here that salt should be 3-5 grams per day and Magnesium 3-4 grams…does that cover the running or should I supplement….can’t get any real info from those who sell electrolytes for runners and don’t want to do too much or waste my money….

    Reply

    1. Virta Health

      Hi Brenda! The hard part is that this is totally based on individual response. 3-5 grams of sodium and 3-4 grams of potassium is a great place to start and then you can adjust based on how you feel!

      Reply

  15. Avatar

    I have been reading about “GKI”. Is achieving ketosis important to a pre-diabetic? My A1c is normal, I have been eating a ketogenic diet for 18 months, but I seldom get blood ketone readings above 0.3.

    Reply

    1. Virta Health

      Hi Lynne! Our clinical trial participants demonstrated improvements in blood sugar, A1c, weight loss, cardiovascular disease risk markers and fatty liver disease markers with an average beta-hydroxybutyrate of 0.31 mmol/L at 1 year into the treatment. You’re in good company!

      Reply

  16. Avatar

    Hi, if i start on Keto diet, will i still be able to consume bird’s nest for beauty purpose?

    Ingredients include bird’s nest and rock sugar. Or should i exclude rock sugar?

    Reply

    1. Virta Health

      The rock sugar will likely make it incompatible with ketosis. I am unfamiliar with the nutrient breakdown of bird’s nest and so I can’t say if it would be too high in carbohydrates. If you are purchasing it with a nutrition label, you will have a better idea of how many carbs you would consume.

      Reply

  17. Avatar

    How can i stop further weight loss?

    I am 10% body fat eating 3300 cals. 7% carb and 25 % protein remainder fats. I exercise x3 in gym for hypertrophy and walk brisk 1hr a day. Do i just increase cals in form of fats?

    Thanks

    Reply

    1. Virta Health

      Hi Steve! We aren’t able to provide specific advice via this forum, however increasing fat has the benefit of increasing the concentration of calories without having to increase the volume of food you are consuming.

      Reply

  18. Avatar

    hi i am having hypothyroidism since 5 years the level of TSH usually ranged between 8-9, i am using 70mg throxine, i had started with keto diet, my latest report says my TSH is 0.06, which is too low. should i stop the tablet and continue the diet??? i weigh 90Kg, and am 35 years old female.

    Reply

    1. Virta Health

      We are unable to provide medical advice in this forum, so we would recommend that you speak with your physician.

      Reply

  19. Avatar
    Kalyani Suresh June 2, 2019 at 6:18 pm

    hi i am having hypothyroidism since 5 years the level of TSH usually ranged between 8-9, i am using 70mg throxine, i had started with keto diet, my latest report says my TSH is 0.06, which is too low. should i stop the tablet and continue the diet??? i weigh 90Kg, and am 35 years old female.

    Reply

    1. Virta Health

      Hi Kalyani, We are unable to provide medical advice in this forum, so we would recommend that you speak with your physician.

      Reply

  20. Avatar

    Is the keto diet recommended as short term for weight loss or a long term lifestyle?

    Reply

    1. Virta Health

      Thank you for your question, Mike! We recommend nutritional ketosis as a long-term strategy to manage your metabolic health, however we have a post that looks at the evidence of short-term ketosis that you might find helpful: https://blog.virtahealth.com/ketosis-vlcd-long-term-type-2-diabetes/

      Reply

  21. Avatar

    Thank you for your great videos on YouTube, and the information provided. I am not diabetic, nor do I suspect I’m insulin resistant, but I am an athlete, and I love the results of the Ketogenic diet on my workouts. I’ve dropped about 15 pounds, which I really wasn’t anticipating, and I’m moving faster on the court then I have in 20+ years.

    I am a Kaiser participant, and I was curious if you have any type of working relation with them, or if you could recommend any Kaiser doctors. I’m having a very difficult time finding someone at this provider. I am in Los Angeles.

    It would be really nice to have an advocate in my doctor, but so far, that is not the case. I’m not sure how to ask for a Insulin Resistance test, or a HbA1c test, or do I even need to do them.

    Any information would be appreciated.

    Reply

    1. Virta Health

      Hi Dave! Thank you for following us! The best thing to do would be to search local low carb groups for recommendations. We work with patients across the US, but Kaiser isn’t currently one of our partnerships. If you would be interested in working with Virta out of pocket, you can go to https://www.virtahealth.com/thevirtatreatment to learn more.

      Reply

  22. Avatar

    I am worried about high blood glucose readings after starting the Keto Diet.

    I have started a Keto diet six weeks ago. I feel good. I have lost about 15 pounds of weight. My carb intake is on average around 30 grams/day. My protein intake is around 90 grams a day. I am a male, 56 years old, Asian Indian and weighed 220 pounds at the start of my diet. I am 6 ft tall. I was obese with body fat estimated to be around 31% using the skin fold test. The goal of my diet is to reduce weight to 170 pounds. For the past year or so I am taking thyroid hormone for hypothyroidism. 4 years ago I has surgery to remove colon cancer and has been cancer free since them. I rigorously measure food intake, blood glucose and ketones daily and keep notes.

    Recently I am showing very high blood glucose (122 mg/dL) in the morning 3 hrs after waking up but before any meal. Before my diet the glucose was around 100 mg/dL. After the first week or so, glucose dropped to a healthy 90 mg/dL. I am concerned about the recent reversal. I am using a reputed blood glucose/ketone meter and I am using the same batch of strips that gave me consistent results earlier.I have researched the web and found that some people experience high glucose dues to a process known as glucose sparing. However, I am considering 122 mg/dL way too high. I have also read conflicting information saying that Keto diet can cause insulin resistance instead of fixing it.

    Is Keto diet dangerous for me? If not, what does this tell me about my metabolism ? How should I, if at all, change my diet to suit my metabolism? Thanks for your help.

    Reply

    1. Virta Health

      Hi Paul! What you’re describing could be related to dawn phenomenon. This post may be helpful: https://blog.virtahealth.com/dawn-phenomenon/

      Reply

  23. Avatar

    Does weight gain on a low carb diet suggest the T3 has gone too low, suggestive of underlying hypothyroidism, or would it suggest another lipid pathway issue? What are the right questions or tests to ask doctors that are inexperienced with low carb to try to address this?

    Reply

    1. Avatar

      T1D teen with very good A1C results on low carb!

      Reply

    2. Virta Health

      Hi Deborah! Unfortunately, there are multiple factors when it comes to weight gain. A great place to start looking is at https://blog.virtahealth.com/top-keto-mistakes/ to see if you are, unintentionally, making any choices that could be hindering your success. I would also recommend reading this article that reviews the variables that go into weight loss: https://blog.virtahealth.com/weight-loss-ketogenic-diet/ . Hopefully those provide you with a place to start!

      Reply

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