Quick answer: Common keto questions cover what to eat, how many carbs to allow, side effects like keto flu, alcohol, dairy, cholesterol and long-term safety. In short: focus on healthy fats, low-carb vegetables and quality protein, keep net carbs low, hydrate and replace electrolytes, and work with your provider if you have health conditions or take medication.
Key takeaways
Keto meals center on healthy fats, low-carbohydrate vegetables and quality protein, and carbohydrates still come from vegetables, nuts and seeds.
Headache, fatigue and nausea are common early side effects, and keto can shift cholesterol levels in different directions for different people.
Alcohol slows ketone production, so if you drink, keeping it occasional is wise.
Food and macros
What can I eat?
Healthy fats, low-carb vegetables and quality protein. See the keto food list.
Can I still eat carbs?
Yes, from vegetables, nuts and berries, kept low. See net carbs.
Do I need to track macros?
It helps at first. See tracking your macros.
Can I eat dairy?
Yes, full-fat options like cheese, butter and Greek yogurt if tolerated.
Side effects and safety
What are common side effects?
Headache, fatigue and nausea early on. See keto flu.
What about cholesterol?
Keto may raise HDL and lower triglycerides, but LDL rises in some people. Check a lipid panel before and during.
Is keto safe long term?
Long-term safety isn’t fully known. Meet nutrient needs and check in with your provider.
Lifestyle
Can I drink alcohol?
Alcohol slows ketone production and lowers inhibitions. If you drink, keep it occasional and choose dry options.
Can vegetarians do keto?
Yes, with eggs, dairy, tofu, nuts and seeds.
Can I build muscle?
Yes, with enough protein and strength training.
What about eating out?
Grilled meat or fish, salads with oil-based dressing and vegetable sides.
Healthy aging lens
Keto is one tool; the habits that support healthy aging are the ones you can keep.
What the research shows
The ketogenic diet has been compared with other diets in randomized trials and in tightly controlled metabolic ward studies.
Keto vs. low-fat over a year or more (Bueno 2013, meta-analysis of 13 randomized trials). This review pooled trials lasting at least 12 months that compared a very-low-carbohydrate ketogenic diet (50 g of carbohydrate a day or less) with a low-fat diet in 1,415 adults. The keto groups lost about 0.9 kg more, had lower triglycerides and slightly lower diastolic blood pressure, and had higher HDL cholesterol. They also had higher LDL cholesterol (about 0.12 mmol/L). A limitation is that the average extra weight loss was small, and people in these trials often drifted away from strict keto over time.
Healthy low-carb vs. healthy low-fat (Gardner 2018, DIETFITS randomized trial). 609 adults without diabetes were coached for 12 months on either a healthy low-fat or a healthy low-carbohydrate diet, with both groups told to focus on whole, minimally processed foods. Weight loss was nearly the same (5.3 kg vs. 6.0 kg), and neither genetic testing nor insulin response predicted who did better on which diet. A limitation is that the low-carb group averaged 30% of calories from carbohydrate, so this was not a strict ketogenic diet.
Keto and appetite (Gibson 2015, systematic review and meta-analysis). This review pooled studies that rated hunger before and during ketosis in people following very-low-energy or ketogenic low-carbohydrate diets. People in ketosis reported being slightly less hungry and having less desire to eat. The authors note that the changes were small; the main benefit was that hunger did not rise as it usually does during weight loss. A limitation is that appetite was self-rated on scales, and the included studies were small and varied.
Strength of the evidence: For most questions, the honest answer is that keto works about as well as other well-planned diets, with some differences in appetite and cholesterol.
When to see a naturopathic doctor
It may be time to see a naturopathic doctor if you have diabetes or take insulin, sulfonylureas or SGLT2 inhibitors (risk of low blood sugar or ketoacidosis), or if you take blood pressure medication or diuretics. The same is true if you have kidney, liver, gallbladder or pancreas disease, or high cholesterol, if you are pregnant, breastfeeding, or have a history of disordered eating, or if you want a keto plan tailored to your labs and goals.
See a medical provider promptly for nausea and vomiting, abdominal pain, confusion, fruity-smelling breath with rapid breathing, or very high blood sugar or ketone readings, which can signal ketoacidosis.
Want a keto plan that’s safe for your health?
A free 15-minute consultation with Dr. Kneessi. No cost, no obligation. In-office in Odenton, MD or by telehealth.
Questions to bring to your clinician
These questions can help you get the most out of your next visit.
Given my cholesterol and health history, what should we watch if I try keto?
Which common keto questions apply most to my situation?
Are there keto myths I should be careful not to follow?
When should I talk with you about changing my keto plan?
Frequently asked questions
How long does it take to enter ketosis?
Often a few days of very low carb eating; it varies.
Can I have cheat meals?
They can interrupt ketosis; plan for flexibility you can sustain.
Does keto help insulin resistance?
It may improve insulin sensitivity for some people.
Is keto safe if I have high cholesterol?
Get your provider’s input and monitor your lipids.
Sources
- Bostock ECS, et al. Consumer Reports of “Keto Flu” Associated With the Ketogenic Diet. Front Nutr 2020. PMID: 32232045. https://pmc.ncbi.nlm.nih.gov/articles/PMC7082414/
- Bueno NB, et al. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr 2013. PMID: 23651522. https://pubmed.ncbi.nlm.nih.gov/23651522/
- Crosby L, et al. Ketogenic Diets and Chronic Disease: Weighing the Benefits Against the Risks. Front Nutr 2021. PMID: 34336911. https://pmc.ncbi.nlm.nih.gov/articles/PMC8322232/
- Boden G, et al. Effect of a low-carbohydrate diet on appetite, blood glucose levels, and insulin resistance in obese patients with type 2 diabetes. Ann Intern Med 2005. PMID: 15767618. https://pubmed.ncbi.nlm.nih.gov/15767618/
- MedlinePlus: Carbohydrates
- MedlinePlus: Cholesterol
- Gardner CD, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion: The DIETFITS Randomized Clinical Trial. JAMA 2018. PMID: 29466592. https://pubmed.ncbi.nlm.nih.gov/29466592/
- Gibson AA, et al. Do ketogenic diets really suppress appetite? A systematic review and meta-analysis. Obes Rev 2015. PMID: 25402637. https://pubmed.ncbi.nlm.nih.gov/25402637/
This article is for educational purposes only and is not medical advice. It does not replace an individual evaluation. Talk with your healthcare provider before starting supplements or changing medications, especially if you are pregnant, nursing, or managing a health condition.
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