Since the ketogenic diet is metabolically powerful, it does come with some potential side
effects.
However, it is unlikely that you or any other person on the diet will experience all of the
known side effects or keto diet sideeffects .
This is known as keto flu.
Even so, I like to discuss them because they can be alarming if you learn
about them through experience alone.
The good news is that these side effects are mostly temporary and resolve themselves as the body adapts to using ketones instead of glucose as the primary fuel.
Nevertheless, since they are unpleasant, let’s discuss them and review methods for minimizing them.
Keto Diet Side Effect 1: Hypoglycemia (Low Blood Glucose)
As carbohydrate intake is lowered, withdrawal symptoms such as nausea, dizziness,
lightheadedness, shakiness, heart palpitations, hunger and headaches may manifest.
These are indicative of hypoglycemia. Drinking an ounce of orange juice may help after 15 minutes or so if the symptoms are intolerable.
For most people, the worst of these effects should fade after the first 4-7 days of carb restriction as the body will begin to adapt to using ketones for fuel.
For some, the hypoglycemia may be intense.
To manage the intense reactions, it may help
to slow the withdrawal process by reducing
carbohydrate levels in stages over several
weeks until you can stay below 12 grams
without a reaction.
As carbohydrate intake is consistently lowered over time, baseline insulin levels will begin to drop as well.
And as they do, carbohydrate intake can be reduced further without withdrawal symptoms.
Side Effect 2: Hunger and Cravings
Hunger and cravings are normal and are usually one the most difficult challenges for those
new to the diet.
However, over time, being “in ketosis” and adapting to this shift in metabolism
has a pronounced dampening effect on hunger.
It may take several weeks for blood ketone
levels to consistently remain high enough (above 1-2mM) to affect physiological hunger.
If hunger is still a problem after two to three weeks on the diet, you may be eating too
many carbs or too much protein for your individual needs.
Review what you’re eating from your food log to be sure that carb and protein intake are low and fat intake is high.
This is not to say that psychological cravings will also disappear, but the biochemical drivers will be greatly reduced.
Eating one or two spoonfuls of coconut oil may increase ketosis and help quell hunger.
Side Effect 3: Weakness, Dizziness and Fatigue
Fatigue, dizziness and feelings of weakness or shakiness can be caused by dehydration and
mineral loss, especially low sodium levels.
Implementing a ketogenic diet usually causes the
body to rid itself of excess water.
Reducing carb intake has the effect of depleting glycogen stores and stimulating the kidneys.
As glycogen is metabolized, urination increases dramatically and minerals such as potassium, calcium, magnesium and sodium are eliminated through the urine.
It is the loss of these minerals which results in fatigue and the symptoms of dehydration:
increased thirst, dry mouth, cramping, weakness, irritability, headache, dizziness, palpitations,
confusion, sluggishness and fainting.
Replace the minerals and fluids by sipping meat and chicken broth and eating more green leafy vegetables.
You can also drink a cup or two of some
homemade mineral water from the recipe at right
to replace lost salt and potassium.*
Also, follow these recommendations on mineral
supplements:
- Calcium and magnesium citrate* supplement as recommended in Appendix A.
- To keep potassium levels up, eat more avocado and green leafy vegetables.
You can also use a product called Cardia Salt which is a salt alternative containing not only sodium, but potassium and magnesium salt as well.
Supplements can also be used, but please
check with your physician about drug
interactions before taking potassium
supplements.
To keep sodium levels up, don’t be afraid to add salt to meals.
If you experience weakness or a “woozy” or “unfocused” feeling, I recommend putting one quarter teaspoon of sea salt in a
glass of water and drinking it, or having a cup or two of the homemade mineral water solution
mentioned above.
The symptoms should get better shortly thereafter if a mineral imbalance is
the problem.
*
NOTE: If you’re taking diuretics or have been advised to avoid salt, talk to your doctor before
adding salt or potassium. Also, if there are kidney problems in your medical history, don't take
oral magnesium supplements without checking with the physician responsible for the care of
these conditions.
 |
| Homemade Mineral water |
Homemade Mineral Water
Add to 1 quart of cold water:
• Exactly 1 level teaspoon of Now
brand potassium chloride powder
AND
• Exactly 1 level teaspoon of table or
sea salt (provides sodium and
chloride).
Mix well and store in the refrigerator.
Drink a cup if you experience the
symptoms mentioned above.
(Hat tip to my friend Austin Voss at
KetoPaleo.com for this recipe.)
Side Effect 4: Constipation
The ketogenic diet is a low fiber, low residue diet, and constipation is a common complaint.
In my experience, constipation can be an indication of a magnesium deficiency, a side effect of pain drugs, and/or dehydration.
Individuals with slow gastrointestinal (GI) motility (due to drugs or disease) should discuss options to address constipation with their physician.
There are drugs for GI motility, such as Milk of Magnesia* as a laxative, MiraLax or Movicol (Polyethylene Glycol 3350) and stool softeners.
Bulky greens such as Romaine lettuce and sautéed mixed greens can also ease constipation.
Fiber bulking products such as psyllium husk powder should not be used if you are currently constipated, but can be used after bowel movements return to normal.
However, individuals with ulcerative colitis, Crohn’s disease or bowel obstruction issues should not use psyllium husk. Talk to your doctor about other options.
Side Effect 5: Muscle Cramps and Dehydration
Muscle cramps are likely a result of water and mineral losses discussed above.
Dosages of diuretic drugs may need to be adjusted as ketogenic diets are naturally diuretic.
It’s important to discuss this first with your prescribing physician before making changes.
For muscle cramps, drink more water and follow the mineral recommendations in Side Effect 3.
Alternatively, follow the recommendations of Drs. Jeff Volek and Stephen Phinney in their book The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-Saving Benefits of
Carbohydrate Restriction Sustainable and Enjoyable.
They recommend taking three slow
release magnesium* tablets such as Slow-Mag or Mag 64 for 20 days, then continue taking one
tablet a day thereafter for muscle cramps.
Side Effect 6: Mild Acidosis Although rare, some people may experience mild metabolic acidosis when implementing a ketogenic diet.
If you develop symptoms such as rapid breathing, excessive fatigue, nausea or vomiting, it may be that ketone levels are too high.
The main treatment is to drink 16-20 ounces
of water and warmed chicken broth which does not have MSG (monosodium glutamate) as an
ingredient. (Avoid bouillon cubes.) The broth will provide some potassium and the extra fluid
will help dilute ketones in your bloodstream.
After taking these first measures, wait for 30
minutes. If symptoms don’t get better, sip an ounce of orange juice and wait for 20 minutes.
If the symptoms don’t subside as this point, contact your health care professional, or go to the
emergency room and let them know you suspect metabolic acidosis.
*NOTE: individuals with kidney problems should not take oral magnesium supplements
without checking with the physician responsible for treating these conditions.
Side Effect 7: Ketone Breath, Ammonia Smell in the Nose
Excess ketones can be expelled from the body via the lungs and the urine.
Having ketone breath is a good thing, since it indicates ketone blood levels are high.
The main ketone in the breath is acetone, which has a distinctive smell. Ketone breath is described as being “fruity.”
And here’s a helpful fact: high levels of acetone in the breath can cause false positive sobriety
tests.
An ammonia smell in the nose is different than ketone breath. It has to do with the breakdown of protein and may be stronger when exercising.
The ammonia smell may also be an indication that too much protein and not enough fat is being consumed.
A ketone meter will give a better indication. If ketones are down, protein intake may need to be lowered, and fat intake increased.
Keto Diet Side Effect 8: Weight Changes
A ketogenic diet lowers blood glucose and insulin, and eventually caloric intake (as hunger subsides).
High insulin levels prevent your body from accessing stored body fat and using it for
fuel.
When insulin levels and calories are lowered, the body is then able to access body fat to use as fuel, and this results in weight loss for most people.
If you experience unintended weight loss, eat
more calories in the form of natural fats (butter,
macadamia nuts, avocados) on a daily basis until the weight loss stops.
If this does not help, eat more protein, or as Miriam Kalamian recommends, add a
quarter cup of cooked legumes (beans, lentils) to your daily menu.
Consuming more medium-chain
triglyceride (MCT) oil and coconut oil are not good choices for this issue as Miriam reports they don’t seem to help with weight stabilization.
If you find it difficult to eat due to gastrointestinal issues or lack of appetite, please partner with a
nutritionist or other trained professional who can offer some suggestions.
There’s a very serious type of muscle-wasting weight loss experienced by late-stage cancer
patients called cancer cachexia.
Doctors often mistake weight loss associated with cachexia for the more benign (and often welcome) weight loss experienced from a ketogenic diet.
They and their dietitians will suggest that you NOT lose weight, even if you are heavy.
They may even prescribe drinks loaded with carbs to keep weight loss to a minimum.
This will work to maintain weight, but it will compromise your goals on the diet as high carb intake will interfere with the lower blood glucose levels and higher ketone levels you’re trying to achieve.
Side Effect 9: Changes in Blood Pressure
High blood glucose and insulin result in greater glycogen stores and hormonal changes
which cause the body to retain water.
For some people, this excess water storage translates into high blood pressure.
Once blood glucose and insulin levels start to drop, the body will burn through the glycogen which will release excess water.
Blood pressure should drop as a result.
For this reason, a physician should monitor all blood pressure medication being taken by the
individual.
Side Effect 10: Vitamin and Mineral Deficiencies
Because certain foods and calories may be restricted, vitamin and mineral supplementation
is strongly recommended while on the diet.
A basic multivitamin/multi-mineral supplement
which contains the RDA for all vitamins and minerals is a good start.
See Appendix A for supplement recommendations.
Final Note on Side Effects and Broth
Many of these side effects can be managed just by making sure your mineral intake is
adequate.
Bone and meat broths as mentioned are a great way to do this.
Kitchen Basics brand offers a good clean chicken, beef and vegetable broth without MSG. If you like to make your own, I have a homemade chicken broth recipe on my this site.
ABOUT HEART PALPITATIONS OR A "RACING HEART :
Some people may experience heart palpitations or a “racing” heart when starting a ketogenic diet.
This is more likely if the person normally has low blood pressure. There are several factors which may explain this symptom:
- First, the person may be insulin resistant, and lowering carbohydrate intake results in transient hypoglycemia.
Hypoglycemia can be associated with not eating often enough at first, or not eating enough in general.
- Second, there may be an electrolyte imbalance. Making some homemade mineral water and drinking a cup in the morning and evening should help if this is the issue.
- Third, some people may have “racing” heart reactions to too much coconut oil or MCT oil. As you add these oils to your diet, start with small amounts and increase over time.
NOTE ON ELEVATED CHOLESTEROL :
Many people have trouble on a ketogenic diet plan because they are alarmed about increasing the amount of fat they eat, especially saturated fat.
This becomes an issue particularly if total cholesterol goes up while on the diet, and the individual’s physician voices concern about higher cholesterol levels.
A physician’s concern is understandable.
The message that eating fat and cholesterol are
harmful has been pounded into the collective American psyche for the last 40 years.
It's also difficult to unlearn the message that high cholesterol is the cause of heart disease.
I understand that these messages have been repeated over and over, but they are both untrue.
Dr. Ron Rosedale, an expert on ketogenic diets writes about this and I have a whole website devoted to dismantling this misconception, as it has caused so much harm.
The real culprit of atherosclerosis is chronically elevated blood glucose and insulin and the associated inflammatory damage to artery walls.
This is why diabetics and those with metabolic
syndrome suffer from higher rates of heart disease.
For most people, following a ketogenic diet improves the risk markers for cardiovascular
health.
Adhering to a ketogenic diet will lower baseline blood glucose and insulin, which will in turn lower inflammation and reduce arterial damage.
The higher saturated fat intake associated
with the diet also increases HDL cholesterol, and at the same time, the lower carb intake decreases triglyceride levels.
These two factors are the major markers for heart disease.
ABOUT NAUSEA :
Most people are not used to eating the amount of fat allowed on a ketogenic diet.
Nausea is common after eating a high fat meal, or after taking coconut oil or MCT oil.
If this happens, try spreading out your fat intake over smaller meals and snacks, consume some of your daily fats between meals, or consider a high-lipase digestive enzyme.
Miriam Kalamian suggests a Pancreatic Enzyme Formula by Pure Encapsulations.
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