Keto and the Menstrual Cycle: Is There Reason To Worry?

It seems every “keto for women” forum abounds with stories about menstrual cycles gone wild in the first few months of keto. Irregular cycles, breakthrough bleeding, and periods lasting much longer than normal are common complaints. Sometimes these stories are cited as evidence that keto isn’t good for women, at least not premenopausal women, and that we need carbs for healthy hormones. Yet, many women don’t notice any changes in their menstrual cycles at all, while others report improvement in PMS symptoms and cycle regularity from the get-go.

What gives? Why do some women’s cycles apparently become wacky when they start keto, while others feel like keto is the key to period bliss? Can keto “mess up” the menstrual cycle?

We know that diet—what and how much we eat—can profoundly affect our hormones. This is true for both women and men. One of the reasons people are so excited about ketogenic diets is specifically because keto shows promise for helping to regulate hormones and improve cellular sensitivity to hormones such as insulin and leptin.

At the same time, women’s hormones are especially sensitive not only to dietary changes but also to downstream effects such as body fat loss. Furthermore, one of the ways women’s bodies respond to stressors is by turning down the dial on our reproductive systems. It’s reasonable to hypothesize, then, that women might have a tougher time adapting to or sustaining a ketogenic diet. Keto can be stressful depending on one’s approach, and that might negatively impact women’s reproductive health. But do the data actually bear that out, or is so-called “keto period” more misplaced hype than genuine fact?

Note that throughout this post, I’m going to use the term “reproductive health” to refer to all aspects of women’s menstrual cycle, reproductive hormones, and fertility. Even if you aren’t interested in reproducing right now, your body’s willingness to reproduce is an important indicator of overall health. When your reproductive health goes awry—irregular or absent periods (amenorrhea) or hormone imbalances—that’s a big red flag. Of course, post-menopausal women can also experience hormone imbalances that affect their health and quality of life (and low-carb and keto diets can be a great option for them).

Menstrual Cycle 101

Let’s briefly review what constitutes a normal, healthy menstrual cycle, understanding that everybody’s “normal” will be a little different. A typical cycle lasts from 21 to 24 days on the short end to 31 to 35 days on the long end, with 28 days being the median. Day 1 is the first day of your period and begins the follicular phase, which lasts until ovulation. Just before ovulation, levels of luteinizing hormone (LH), follicle stimulating hormone (FSH), and estradiol (a form of estrogen) spike. Next comes the luteal phase covering the approximately 14 days from ovulation to menses. LH, FSH, and estradiol drop, while progesterone rises. Estradiol bumps up again in the middle of the luteal phase. If a fertilized egg is not implanted, menstruation commences, and the whole cycles starts over again. All this is regulated by a complex communication network under the hypothalamic–pituitary–gonadal (HPG) axis, which is closely tied to the actions of the adrenal (the A in HPA axis) and thyroid glands.

Across the cycle, fluctuations in body weight are common as fluid is retained and then released along with shifts in estrogen and progesterone. Changes in blood glucose are also normal, and insulin-dependent diabetics often find that they need to adjust their dose at different times of their cycles to keep their blood sugar in check. The most common pattern is higher blood glucose readings in the pre-menstrual period (the second half of the luteal phase), and lower readings after starting your period and before ovulation. This is generally attributed to the fact that progesterone, which is highest during the luteal phase, is known to reduce insulin sensitivity. However, different women experience different patterns, which can also be affected by other factors such as oral contraceptive use.

Normal fluctuations in insulin resistance and blood glucose can mean that women get lower ketone readings at certain times of the month than others. When these occur premenstrually—and so they tend to coincide with a period of (transient) weight gain and food/carbohydrate cravings—women often feel as though they are doing something wrong. Rest assured that these variations reflect normal physiology.

The many factors that affect your cycle and the levels of your sex hormones include: other hormones, gut health and microbiome, metabolic health (e.g., insulin sensitivity), environmental toxins, stress, sleep, immune health, nutrient deficiencies, activity level and energy expenditure, and age. Each affects the others, and all (except age of course) can be affected by diet. It’s no surprise, then, that it can be extremely difficult to pin down a root cause of menstrual changes or reproductive issues.

What the Research Tells Us About Keto and Menstruation

As I said at the outset, there are lots of anecdotes, both positive and negative. In my experience, most women whose cycles seem to go crazy when they start keto find that things get back to normal—and often a better version of normal—after a few months.

First, it’s tricky to determine the effects of keto per se, since many people combine a ketogenic diet with calorie restriction (intentionally to lose weight or unintentionally due to the appetite suppressing effects of keto) and with fasting (intermittent and/or extended). Each of these can independently impact the factors listed above, lead to weight loss, and affect the menstrual cycle and reproductive health.

So, is there any evidence that keto itself causes changes to menstruation?

The scientific evidence is scant….

The one statistic you’ll see floating around the interwebs is “45% of (adolescent) females experience irregular menstrual cycles on keto.” This statistic comes from one small study of adolescent girls using a therapeutic ketogenic diet to treat epilepsy. Six of the twenty girls reported amenorrhea (loss of period) and three were diagnosed with delayed puberty. However, the ketogenic diet used for epilepsy is different and usually much stricter than an “everyday” keto diet needs to be, and epilepsy is frequently associated with menstrual dysfunction regardless of diet.

To extrapolate the findings of this study and argue that nearly half of teenage girls (or women generally) are likely to experience menstrual problems from going keto is a huge leap.

The fact is, I’m unable to find any studies done in healthy human females (or mice for that matter) demonstrating that otherwise normal menstrual cycles are disturbed by going keto.

5 Ways Keto-Related Factors *Might* Affect Your Menstrual Cycle

With the limited amount of research looking directly at keto and menstruation, let’s look first at whether there are direct effects of carbohydrate restriction or elevated ketone production on the menstrual cycle. Those are the defining characteristics of keto and what differentiates keto from other ways of eating. Then we can examine indirect effects that occur due to factors such as weight loss. These are not unique to keto, though they might be more likely on a ketogenic diet compared to other ways of eating.

Carbohydrate Restriction

There is no real body of evidence that looks at ketogenic levels of carb restriction and menstruation, but there are some clues. In this small study, functional hypothalamic amenorrhea (FHA) was associated with dietary fat restriction; women with FHA actually ate non-significantly more carbs than matched controls and nearly identical total calories. Likewise, in this small study, FHA was associated with lower fat intake but no significant difference in carb intake.

This meta-analysis looked at the effect of low-carb (not keto) diets on markers of reproductive health among overweight women. The researchers found four studies that examined effects on menstruation; all showed improved menstrual regularity and/or ovulation rates. Of six studies that looked at levels of reproductive hormones, five reported significant improvements.

Carb restriction also results in decreased insulin production. Hyperinsulinemia and insulin resistance are frequently associated with polycystic ovarian syndrome (PCOS), one of the leading causes of female infertility and a frequent cause of menstrual irregularity. There is currently a lot of interest in using keto to treat PCOS, but only one small study has so far directly tested the effectiveness of a ketogenic diet to treat PCOS, with positive results.

Ketones

No studies have looked at the direct effects of ketones on menstruation.

Weight Loss

Of course weight loss is not unique to keto, but keto can be very effective for weight loss. Some women experience rapid weight loss when first starting a keto diet. Weight loss in and of itself can impact menstruation through a variety of pathways (and, of course, keto isn’t the only way people lose weight). A key way is by reducing the hormone leptin. Leptin’s main job is to communicate energy availability to the hypothalamus—high levels of leptin tell the hypothalamus that we have enough energy on board, which also means we can reproduce. Low leptin can disrupt the menstrual cycle and is linked to hypothalamic amenorrhea.

Body fat loss can also affect estrogen levels since estrogen is both stored and produced in adipocytes (fat cells). While fat loss in the long term will decrease estrogen production, it is possible that rapid fat loss might temporarily raise estrogen levels and can also affect estrogen-progesterone balance. These transient changes in estrogen levels might underlie some of the menstrual irregularities women report.

Stress

Stress can impact the menstrual cycle in myriad ways. Cortisol acts on the hypothalamus and pituitary glands, affecting hormone levels, sleep, immune function, and gut health, to name a few. Diets can be a source of stress, both at the physiological and psychological levels. Keto has a reputation for being especially stressful because it is more restrictive than other low-carb diets, but this can be mitigated by following the Keto Reset tips for women.

Thyroid Function

Thyroid dysregulation is another common cause of menstrual irregularities, and there remains a pervasive belief that keto is bad for thyroid health. Indeed, the thyroid is sensitive to nutrient deficiencies and caloric restriction, and thyroid hormones, especially T3, do frequently decline on keto. However, as Mark has discussed in a previous post, changes in T3 levels might not be a problem, especially in the absence of other problematic symptoms. Moreover, many practitioners now use keto as a cornerstone in their treatment of thyroid disorders.

What Should I Take From These Findings?

The first takeaway: there just isn’t much direct evidence about how keto might affect your menstrual cycle, positively or negatively. We have some studies suggesting that low-carb diets improve some aspects of menstruation and reproductive health, but keto is more than just another low-carb diet. Ketones themselves have important physiological properties, such as being directly anti-inflammatory, which might positively impact women’s reproductive health.

Second, the ways that keto is likely to (negatively) affect menstruation aren’t unique to keto, they’re common to any diet: hormone shifts mediated by energy balance, stress, and weight loss.

Furthermore, since keto is so often combined with caloric restriction, time-restricted eating, and fasting, even the anecdotal evidence might not be able to tell us all that much. If a woman is eating ketogenically, in a big caloric deficit, and doing OMAD (one meal a day), and her leptin plummets, how are we to know what really caused it? We don’t have good evidence that otherwise healthy women start a well-executed ketogenic diet and end up messing up their menstrual cycles.

That said, women do need to be cognizant of the sum total of the signals they are sending their bodies when it comes to energy availability and stress. A lot of women come to the keto diet with a history of adrenal, thyroid, metabolic, and reproductive issues. It’s important that they’re extra careful about how they approach keto. Done correctly, it might be just what the doctor ordered. I encourage any woman who’s dealing with other hormonal issues to work with a medical practitioner to tailor a keto diet to her unique needs.

But I’m Telling You, Keto Made My Period Go Haywire!

Ok, I believe you, really! But changes do not necessarily equal dysfunction. It is normal to experience hormone fluctuations when you make a massive—or even a relatively small but important—shift in your nutrition. Sometimes those fluctuations are unpleasant or unwanted, such as a period that lasts 14 days or one that arrives a week before you planned while you’re on vacation. However, that doesn’t make them bad from a health perspective. We need to respect that our bodies are dynamic systems. Changing the input will invariably change the output, and the system might need a few months to adapt to a new normal.

If your cycle goes wonky but you’re otherwise feeling good, give it a few months to sort itself out. If after a few months it’s still all over the place (or definitely if you’re having other disruptive symptoms), enlist help. In the meantime, check to make sure you’re not short-changing yourself nutritionally or calorically. Scale back on fasting efforts, and consider shifting more toward a traditional Primal way of eating.

At the end of the day, if you go keto and experience negative effects, stop. Keto is super hyped right now, but if your body is sending you clear signals that keto is not a good approach for you at this time, don’t do it. You can always try again later. It might be that your first attempt at keto didn’t work, but with a few adjustments and some experimentation over time you can find a version of keto that works for you.

Thanks for reading, everyone. Do you have comments, questions, or feedback? Let me know below.

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References:

Comninos AN, Jayasena CN, Dhillo WS. The relationship between gut and adipose hormones, and reproduction. Human Reproduction Update 2014; 20(2): 153–174.

Fontana R, Della Torre S. The Deep Correlation between Energy Metabolism and Reproduction: A View on the Effects of Nutrition for Women Fertility. Nutrients. 2016;8(2):87.

Klok MD, Jakobsdottir S, Drent ML. The role of leptin and ghrelin in the regulation of food intake and body weight in humans: a review. Obesity Reviews 2007;8(1):21-34.

Meczekalski B, Katulski K, Czyzyk A, Podfigurna-Stopa A, Maciejewska-Jeske M. Functional hypothalamic amenorrhea and its influence on women’s health. J Endocrinol Invest. 2014;37(11):1049–1056.  

Tena-Sempere M. Roles of Ghrelin and Leptin in the Control of Reproductive Function. Neuroendocrinology 2007;86:229-241.

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13 Keto-Friendly Fiber Foods

While some keto or low-carb proponents claim fiber is useless at best and actively harmful at worst, I come down on the side that says fiber is probably helpful for most people. Some folks have persistently better responses to low- or no-fiber keto diets, and I won’t argue with that—I’ve seen it happen and I’ve read the studies where de-emphasizing fiber can actually improve constipation, for example.

I’ll just say that I have an opposite reaction, and, most importantly, I love eating a variety of plant foods that also happen to contain a ton of great nutrients in addition to fiber.

Do I buy into the idea that fiber is important because it is every human being’s responsibility to produce as much colonic bulk as humanly possible? No.

Do I think we should be consistently pushing the limits of our digestive tracts, performing feats of bathroom heroism so momentous they border on Herculean, and making sure the toilet bowl buckles beneath us? No.

The real value of fiber lies not in its coarseness, its tendency to form colonic bulk, to keep us topped off. The true value lies in its fermentability. A fermentable fiber is a prebiotic fiber—fiber that feeds our gut bacteria.

I won’t get into the many roles our gut bacteria play in our health today (I’ve covered that before. 1, 2, 3).

I will, however, explain why we need to be feeding our gut bacteria. Our gut bacteria form a physical barrier against incursions and colonization by pathogenic bacteria; they take up room along the gut lining so pathogens can’t. If we don’t feed our gut bacteria with prebiotics, it won’t be around to protect us. After antibiotic treatment where both good and bad gut flora are indiscriminately targeted and wiped out, pathogenic obesity-promoting bacteria take advantage of the open space. That’s a worst-case scenario, but it shows what can happen when the harmony of the gut is disturbed by antibiotics or, to a less extent, a lack of fermentable prebiotic fibers.

When our gut bacteria eat prebiotics, they also give off metabolites like butyric acid—a short chain fatty acid that our colonic cells use as an energy source and which improves metabolic health.

Gut bacteria also convert antinutrients like phytic acid into nutrients like inositol. The almond meal-obsessed keto eater would do well to have a powerful gut biome set up to convert all that phytic acid to inositol.

Now, some writers will come up with specific blends of fibers, powders and gums to create the “optimal” prebiotic diet for your gut bacteria, but that’s pretty silly. The gut is a complicated place. We’ve barely begun to even identify all its inhabitants. To think we know the precise blend of isolated fiber that will make them flourish, and then act on that, is a mistake.

A better option is to eat foods that contain fiber. Some of the prebiotic fibrous foods with the best nutrient profiles also happen to be extremely keto-friendly.

1) Almonds and Pistachios

Nuts are usually favored in health-conscious circles for a few reasons. They like the monounsaturated fat. They like the mineral profile, or the complete protein, or their ability to dissemble into nut meals and form baked goods. But what gets short shrift is the fiber content. Now, I can’t speak for other nuts, but almonds and pistachios in particular contain fiber with potent prebiotic effects. People who eat almonds and to an even greater extent pistachios end up with improved gut bacteria profiles.

2) Green Bananas

Ripe bananas are difficult to squeeze into a ketogenic diet. The green banana—an unripe one—is mostly resistant starch, a type of starch that cannot be digested and travels untouched until colonic bacteria metabolize it. It’s one of the best stimulators we know of butyric acid production. And sure, you could do a spoonful of raw potato starch to get your resistant starch, but the beauty of the green banana is that it also provides potassium, another nutrient that some find difficult to obtain and stay keto.

3) Wild Blueberries

Blackberries, boysenberries, raspberries, and strawberries are all loaded with fiber, and you should eat them. They’re lower carb than you think, they’re loaded with polyphenols, and topped with some real whipped cream they make a fantastic dessert. But wild blueberries are special. They’re smaller than other berries, which increases the amount of skin per ounce you get, and skin is where all the polyphenols and fiber lie. Heck, even the blueberry’s polyphenols have prebiotic effects on the gut biome.

4) Mushrooms

A few years ago, I wrote a whole post on mushrooms. Suffice it to say, they’re quite wonderful, bordering on magical. I did not discuss the fiber they contain. It turns out that all the various mushroom polysaccharides/fibers, including beta-glucans, mannans, chitin, xylans, and galactans also act as potent prebiotics that improve the health of the host.

5) Avocado

Your standard avocado has about 12-15 grams of fiber, if you eat the whole thing. I

6) Jicama

Great with chili powder, salt, and lime juice, jicama is about 11 grams of carbs per cup, but half of those are inulin, a potent prebiotic fiber with a tendency to really ramp up butyrate production.

7) Onions

Onions are another fantastic source of inulin. They go into almost every dish of every cuisine, so there’s no excuse not to be eating onions.

8) Garlic

I’ve been known to treat garlic like a vegetable, roasting an entire cast iron pan full until brown and sweet and chewy. They’re another great source of prebiotic fiber.

9) Leeks

Leeks have more inulin than onions. Try them crispy in egg scrambles.

10) Broccoli

Broccolini is a major part of my favorite meal of the day—my Big-Ass Keto Salad. Broccoli (and cruciferous vegetables in general) has been shown to have modulatory effects on the gut biome.

11) Sauerkraut

Kraut gives you two in one. It’s a fermented food, which is great for the gut biome. And it’s cabbage, which is very fibrous. Even pasteurized kraut improves gut health.

12) Dark Chocolate

Dark chocolate, the good stuff with a high cacao content (85%+) and low sugar content, is an incredible source of prebiotic fiber. Eat more of it.

13) Animal Fiber

Obligate carnivores like cheetahs who don’t eat any plants (willingly) still have gut bacteria. These gut bacteria thrive on “animal fiber,” the gristle and cartilage and other bits of connective tissue that comprise a good 20-30% of the walking weight of a prey animal. Humans are not obligate carnivores, but eating the entire animal has been a mainstay of advanced hominid existence for millions of years. I find it very likely that something, someone, somewhere inside our guts is breaking down the animal fiber we eat—so you’d better be eating some!

Not so tough, is it? It’s not like I’m suggesting you load up on bran muffins, psyllium smoothies. I don’t want you dumping flax meal into everything or munching on those awful fiber gummies. Just eat some basic, healthy, low-carb plant matter—foods that don’t really scream “fiber”—and the rest will take care of itself.

What’s your favorite low-carb source of fiber? Let me know down below.

Thanks for reading, everyone.

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References: 

Hernández E, Bargiela R, Diez MS, et al. Functional consequences of microbial shifts in the human gastrointestinal tract linked to antibiotic treatment and obesity. Gut Microbes. 2013;4(4):306-15.

Ukhanova M, Wang X, Baer DJ, Novotny JA, Fredborg M, Mai V. Effects of almond and pistachio consumption on gut microbiota composition in a randomised cross-over human feeding study. Br J Nutr. 2014;111(12):2146-52.

Jiao X, Wang Y, Lin Y, et al. Blueberry polyphenols extract as a potential prebiotic with anti-obesity effects on C57BL/6 J mice by modulating the gut microbiota. J Nutr Biochem. 2019;64:88-100.

Jayachandran M, Xiao J, Xu B. A Critical Review on Health Promoting Benefits of Edible Mushrooms through Gut Microbiota. Int J Mol Sci. 2017;18(9)

Nielsen ES, Garnås E, Jensen KJ, et al. Lacto-fermented sauerkraut improves symptoms in IBS patients independent of product pasteurisation – a pilot study. Food Funct. 2018;9(10):5323-5335.

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The Best 17 Keto-Vegan-Paleo Recipes

Thanks to the good folks at Paleohacks for today’s recipe.

Is it possible to go keto while omitting all dairy and animal products as well? It might seem difficult, but these 17 keto-friendly vegan and Paleo recipes can get you started.

The biggest challenge to going keto (and otherwise restricting your diet) is the frustrating perceived lack of variety when it comes to meals. We’re here to prove that even when following the keto, Paleo and vegan diets, you can still eat well.

From breakfasts, to snacks, to lunch, dinner and dessert, there’s something for every meal of the day. Enjoy fluffy coconut flour flatbread to sandwich your favorite toppings, or healthy mint chocolate fudge for a treat. You’ll find inspiration all over this list.

These five-ingredient, five-minute low-carb crunch protein bars are basically healthy candy bars. Plus, there are lots of modifications you can follow to best suit your diet.

This easy, fluffy flatbread will fool anyone—it’s just as good as the original, gluten-laden kind. Psyllium husk functions as the “egg-like” binder in this recipe, making it totally vegan in addition to Paleo and keto.

This simple Shamrock shake recipe is way better than the fast food original, but just as (naturally) green—thanks, avocado! Vanilla and mint extracts lend the shake its distinct flavor.

Need a craving-busting chocolatey treat? These chocolate espresso bombs use whole ingredients, including cacao powder, nut butter and espresso powder. They’re full of healthy fats that will keep you satiated in between meals.

This inventive bento box assemblage includes seaweed “noodles” with your choice of raw or toasted almonds, an herbaceous heirloom tomato and cucumber salad, protein-packed guacamole and chunks of coconut and carrot. It makes for one refreshing, colorful and healthy lunch!

Packed with Mexican spices like cumin and cilantro, this Mexican cauliflower rice makes the perfect accompaniment to any main dish.

Silky mint chocolate fudge that’s dairy and sugar-free? It’s true! This simple recipe is ready in under an hour and requires only a blender and a fridge.

The secret to these crunchy, chocolate mint, no-bake protein bars is the crunchy almond butter—but smooth almond butter will also work in a pinch. Adorn your bars with chia seeds, coconut, cacao nibs or almonds for added flavor and texture.

These chocolatey-coffee-nutty treats will keep you satiated all day long, thanks to the addition of almonds, flax meal, hemp seeds, almond butter and coconut oil. Be sure to omit the maple syrup or swap in a keto-compliant sweetener.

Don’t be fooled by the pictures—there’s no actual pasta to be found here! Kohlrabi noodles make for a flavorful, healthy dish, while a homemade, dairy-free Alfredo adds an ultra-creamy mouthfeel. This recipe uses pre-prepped noodles and cauliflower rice, but you can always make those at home with a food processor and spiralizer.

These fat bombs are loaded with puckering citrus flavor from lemon juice and zest as well as coconut butter, coconut oil and low-carb blueberries—or whatever berries you prefer.

Need a big bowl of comfort, with none of the guilt? This low-carb mac and cheese recipe uses hearty cauliflower in place of noodles, while tahini, olive oil and spices make it super creamy and tasty.

Well-spiced, creamy spinach gets whipped up quickly in the Instant Pot. Opt for coconut oil over ghee to keep it vegan, and serve over a bed of cauliflower rice.

These simple, uber-creamy and chocolatey fudgesicles take minutes to prep. Opt for stevia over the maple syrup and add more coconut milk to keep it keto.

Need a big bowl of Mediterranean-inspired, veggie-packed goodness? This salad boasts cauliflower, artichoke hearts, bell pepper, cucumber, tomatoes and more.

This simple tabbouleh recipe subs in cauliflower for traditional grains. It’s herbaceous, lemony and perfect to dip all your favorite vegetables in.

Missing bread on your restricted diet? This magic, low-carb mug bread comes together in minutes and requires only a handful of wholesome ingredients. Be sure to use a vegan egg substitute to keep it vegan.

Thanks again to Paleohacks for the awesome recipe list today. Have your own favorite low-carb plant-based favorites? Share below. 

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Top 12 Keto Blogs

With the explosion of keto, there’s an ever growing constant stream of new information about the significant benefits, supposed risks, and varying “rules” for how to adopt a keto diet. As with most things, it’s easy to get sucked into information overload. (And that doesn’t even take into account the hype that unfortunately gets distributed like wildfire around the Internet.) You want sources you can count on for facts, reason, and utility. Here are twelve solid sources I’d recommend for intelligent commentary, sound science, and useful ideas.

1) Mark’s Daily Apple

Sure, this isn’t an exclusively keto blog. It’s a Primal living blog—with attention to all the components that figure into a healthy lifestyle and fulfilling life. But keto is a powerful tool I use within the Primal Blueprint template. As most of you already know, I approach keto specifically through a Primal lens—what I call a Primal-keto approach to keto living that prioritizes optimum nutrition with the least amount of pain, suffering and sacrifice. I know it’s been working for a lot of people, and I’ll continue to to write on it as well as all the other elements of a healthy life. Four particular resources I’d suggest to folks new to keto: the MDA Keto Hub, our Keto Recipes, the Primal Blueprint Keto Podcast, and our private Keto Reset Facebook Group. They’re all free resources for anyone to use and enjoy. For those who want to receive an additional Mark’s Daily Apple monthly email with exclusive information and commentary on keto, you can sign up below for the Keto Reset Digest (also free).

2) Virta Blog

Virta is a groundbreaking health organization using keto to treat—even reverse—type 2 diabetes and associated metabolic disorders. The Virta Blog is an must-read, providing a mix of cutting edge science, easy to understand articles regarding practical aspects of going keto, and inspiring success stories.

3) Tuit Nutrition

I love Amy Berger’s common sense approach to keto on Tuit Nutrition. She calls her approach Keto Without the Crazy, and that about sums it up. Her articles are long but very worth reading.

4) Ruled.me

At Ruled.me you’ll find mostly long-form articles that contain a ton of information about the keto diet. The site also provides an extensive recipe collection and other resources.

5) Healthful Pursuit

Healthful Pursuit is the home of Nutrition Educator and keto guru Leanne Vogel. Leanne provides a blend of blog posts, videos, and recipes to help you go keto in a healthy way. Much of the content is focused on keto for women, but men and women alike can benefit from the info provided.

6) Calories Proper

At Calories Proper, Dr. Bill Lagakos covers a wide range of topics related to nutrition, fasting, circadian biology, and much more. While it’s not a keto blog per se, keto is a frequent topic. In any case, you’re sure to learn a lot from the content here, which is heavily focused on reviewing and critiquing empirical research studies in an understandable way.

7) Ketogenic Athlete

Ketogenic Athlete is a well-rounded blog for strength and endurance athletes who are interested in using keto for training and performance.

8) The MAF Files at philmaffetone.com

Dr. Phil Maffetone has been using low-carb and keto diets to help athletes achieve breakthrough athletic performance for decades. His 180-age formula is a cornerstone of my Primal Endurance approach to become and fat- and keto-adapted athlete. The MAF Files covers a variety of topics that will be of interest to Primal and keto athletes.

9) HVMN

HVMN offers the only commercially available ketone ester supplement. The blog reflects their target audience: athletes and other high performers who are interested in using diet and lifestyle modifications—and possibly exogenous supplementation, of course—to harness the power of ketones.

10) Elana’s Pantry

Elana Amsterdam has long been one of my go-to sources for healthy, delicious paleo recipes, but more recently she has been using keto as part of her strategy to address her MS. I’ve never made an Elana’s Pantry recipe that wasn’t excellent. She also writes about a variety of topics related to health.

11) Castaway Kitchen

Christina Kurp shares how she used a combination of AIP and keto to fix her own health issues. Part wellness blog, part scrumptious recipe collection, Castaway Kitchen is a great resource for anyone looking for food inspo, especially if you have dietary restrictions.

12) Cast Iron Keto

Plainly put, Cast Iron Keto has food I like to eat: simple, delicious, keto-friendly. You’ll find lots of keto-fied classics here suitable for kids and non-keto types (making dinner that much easier).

Thanks for stopping in today, everyone. Have a favorite you didn’t see here? Share down below. Take care.

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Dear Mark: Antibiotic Recovery, Sprinting on Keto, Preparing for Bad Sleep

For today’s edition of Dear Mark, I’m answering three questions. First up, what can a person do to help their gut recover its barrier function after too many antibiotics? Are there any foods, supplements, or dietary strategies? Second, what can explain rapid fatigue during sprint sessions on a keto diet? Is this simply part of the deal, or are there modifications you can make? And finally, what do I do when I know I’m going to get a bad night’s sleep?

Let’s go:

Mark – any idea how to cure leaky gut caused by overuse of antibiotics. Tried raw dairy for a month to no avail.

First of all, check out my post on leaky gut. Read through it and follow my suggestions for preventing and treating intestinal permeability. It’s a great place to start.

Then, let’s look at some other interventions that have been shown to improve recovery from antibiotic therapy. While most of the studies referenced don’t explicitly describe antibiotic-induced leaky gut, anything that improves gut function and restores healthy gut bacteria will also normalize leaky gut—since it’s the eradication of native gut bacteria that causes antibiotic-induced leaky gut.

Fermented dairy. You tried raw dairy. What about fermented dairy? While raw dairy has its merits, it’s fermented dairy that just works for recovery from antibiotics. Yogurt is a good option to try, although the evidence is a bit inconsistent. Kefir is probably better; it’s been shown to improve patients’ tolerance to triple antibiotic therapy during treatment for H. pylori infection. This is even worth consuming during antibiotic therapy, as many of the probiotic bacteria found in fermented dairy show resistance to common antibiotics.

Fermented vegetables like sauerkraut are also must-eats. The fermented cabbage contains ample amounts of L. plantarum, a bacteria strain that’s been shown to prevent antibiotic-related diarrhea in piglets (another omnivorous mammal). Good options exist in stores (check the refrigerated section; shelf-stable pickles and kraut aren’t lactofermented), and even more are available in farmer’s markets, but the best way to get the most bacteria-rich vegetable ferments is to make your own.

Supplemental probiotics are fantastic here, too: large doses of the desired microorganisms delivered directly to your gut. Some of the strains used in Primal Probiotics, like B. clausii and S. boulardii, have been shown to be effective against antibiotic-related diarrhea, so that could be a good choice.

Don’t forget the food for your gut bugs: prebiotics. You need to eat fermentable fibers and other prebiotics like resistant starch to support the growth and maintenance of the helpful bacteria that improve gut barrier function. Consider eating cooked and cooled potatoes, unheated potato starch, leeks, garlic, onions, green bananas, apples, pears, berries, and pretty much any fruit or vegetable you can get your hands on. Plenty of them are low-carb enough to work on a keto diet, if that’s your desire. Oh, and dark chocolate is a great source of fiber and polyphenols, which have prebiotic effects in the gut.

Incorporate intermittent fasting. Going without food for a spell gives your gut a break and induces autophagy, which can help with tissue healing.

Get dirty, too, to introduce potentially helpful bacteria. Go out and garden. Go barefoot at the park (do your due/doo diligence, of course) and practice tumbling, or roughhouse with your kids (or friends). Don’t immediately rush to wash your hands all the time (unless you’ve been handling raw meat and/or dog poop).

Whatever you do, don’t stress too much about the antibiotics you had to take. Stress is awful for gut health and you’ve already taken the antibiotics—which were probably necessary—so that ship has sailed.

If probiotics with prebiotics aren’t helping (or making things worse), you might want to try going the opposite direction—removing all plant foods and doing a carnivore diet for a few weeks. While I have doubts about the long term viability and safety of eschewing all plant foods, enough people have written to me about their great experiences resolving gut issues with a bout of carnivory that it’s worth trying.

When on a strict keto plan, why do I become so quickly fatigued while attempting a HIT sprint workout?

The first five seconds of a sprint are primarily powered by phosphocreatine (or creatine phosphate), a “quick burst” energy source that burns hot but disappears quickly. This is the stuff used to perform max effort Olympic lifts, short sprints, and other rapid expressions of maximum power. It doesn’t last very long and takes a couple minutes to replenish itself. A keto diet doesn’t affect our creatine phosphate levels. If anything, it should improve them if we’re eating meat.

After five seconds, anaerobic metabolism of muscle glycogen provides the lion’s share of your energy needs. The longer your sprint, the more glycogen you’ll burn. The less glycogen you carry in your muscles, the shorter your sprint. Because once you run out of creatine phosphate and glycogen, you’re left with aerobic metabolism—great for longer distances, not so great for max effort sprints.

Keto dieters tend to walk around with less glycogen in their muscles. If that’s the case, longer sprints will be harder.

If you want to keep sprinting:

Do shorter sprints. Try a 10-second hill sprint rather than a 20-second one. Really go hard. Heck, you can even do 5-second sprints and derive major benefits; just do more of them and make sure to recover in between. There’s no rule saying you have to sprint for 20-30 seconds.

Take longer rest periods. Give your muscles a chance to replenish more creatine phosphate (and take creatine or eat red meat and fish, which are the best sources of dietary creatine).

Eat 20-30 grams of carbs 30 minutes before a sprint session. See if it helps. Alternatively, you can eat the 20-30 grams of carbs after the sprint session to replenish lost glycogen stores (without really impacting your ketone adaptation, by the way).

Most people figure out their sprinting sweet spot while doing keto. They may have to play around with the dosages, durations, and rest periods, but you can usually make it work. Be open to trying new permutations.

If you knew you were going to have a poor nights sleep, what measures would you take to reduce some of the damage?

I would exercise hard that night. Normally, a bad night’s sleep tanks your insulin sensitivity the next day, giving you the insulin resistance and glucose tolerance of a diabetic. A good hard interval session the night before a bad night’s sleep, however, counters the next-day insulin resistance.

I would make the most of it. Don’t dawdle. Don’t beat yourself up because of the impending sleep deprivation. It’s going to happen. You have to accept it, not let it destroy you.

Enjoy it. A little-known acute treatment for depression is sleep deprivation. That’s right: a single night of sleep deprivation has been shown to ameliorate depression in patients with clinical depression. Sometimes the effect lasts up to several weeks. It’s not a long term or sustainable fix for clinical depression, obviously, and you can’t do it every single night—chronic sleep deprivation is a major risk factor for developing depression—but it can improve your mood if you give in to it.

I would set out a jar of cassia cinnamon. I always add cassia cinnamon to my coffee in the morning after bad sleep; cassia cinnamon the day after a bad night’s sleep attenuates the loss of insulin sensitivity and glucose tolerance.

That’s it for today, folks. Thanks for writing in and reading! If you have any input on today’s round of questions, let me know down below.

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References:

De vrese M, Kristen H, Rautenberg P, Laue C, Schrezenmeir J. Probiotic lactobacilli and bifidobacteria in a fermented milk product with added fruit preparation reduce antibiotic associated diarrhea and Helicobacter pylori activity. J Dairy Res. 2011;78(4):396-403.

Bekar O, Yilmaz Y, Gulten M. Kefir improves the efficacy and tolerability of triple therapy in eradicating Helicobacter pylori. J Med Food. 2011;14(4):344-7.

Erginkaya Z, Turhan EU, Tatl? D. Determination of antibiotic resistance of lactic acid bacteria isolated from traditional Turkish fermented dairy products. Iran J Vet Res. 2018;19(1):53-56.

Yang KM, Jiang ZY, Zheng CT, Wang L, Yang XF. Effect of Lactobacillus plantarum on diarrhea and intestinal barrier function of young piglets challenged with enterotoxigenic Escherichia coli K88. J Anim Sci. 2014;92(4):1496-503.

Jitomir J, Willoughby DS. Cassia cinnamon for the attenuation of glucose intolerance and insulin resistance resulting from sleep loss. J Med Food. 2009;12(3):467-72.

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The Definitive Guide To Autophagy (and 7 Ways To Induce It)

Biological systems are self-maintaining. They have to be. We don’t have maintenance workers, mechanics, troubleshooters that can “take a look inside” and make sure everything’s running smoothly. Doctors perform a kind of biological maintenance, but even they are working blind from the outside.

No, for life to sustain itself, it has to perform automatic maintenance work on its cells, tissues, organs, and biological processes. One of the most important types of biological maintenance is a process called autophagy.

Autophagy: the word comes from the Greek for “self-eating,” and that’s a very accurate description: Autophagy is when a cell consumes the parts of itself that are damaged or malfunctioning. Lysosomes—members of the innate immune system that also degrade pathogens—degrade the damaged cellular material, making it available for energy and other metabolites.  It’s cellular pruning, and it’s an important part of staving off the worst parts of the aging process.

In study after study, we find that impairment to or reductions of normal levels of autophagy are linked to almost every age-related degenerative disease and malady you can imagine.

  • Cancer: Autophagy can inhibit the establishment of cancer by removing malfunctioning cellular material before it becomes problematic. Once cancer is established, however, autophagy can enhance tumor growth.
  • Diabetes: Impaired autophagy enables the progression from obesity to diabetes via pancreatic beta cell degradation and insulin resistance. Impaired autophagy also accompanies the serious complications related to diabetes, like kidney disease and heart failure.
  • Heart disease: Autophagy plays an important role in all aspects of heart health.
  • Osteoporosis: Both human and animal studies indicate that autophagy dysfunction precedes osteoporosis.
  • Alzheimer’s disease: Early stage Alzheimer’s disease is linked to deficits in autophagy.
  • Muscle loss: Autophagy preserves muscle tissue; loss of autophagy begins the process of age-related muscle atrophy.

Okay, so autophagy is rather important. It’s fundamental to health.

But how does autophagy happen?

The way it’s supposed to happen is this:

Humans traditionally and historically lived in a very different food environment. Traditionally and historically, humans were feasters and fasters. While I don’t think our paleolithic ancestors were miserable, wretched, perpetually starving creatures scuttling from one rare meal to the next—the fossil records show incredibly robust remains, with powerful bones and healthy teeth and little sign of nutritional deficits—they also couldn’t stroll down to the local Whole Foods for a cart full of ingredients. Going without food from time to time was a fundamental aspect of human ancestral life.

They worked for their food. I don’t mean “sat in a cubicle to get a paycheck to spend on groceries.” I mean they expended calories to obtain food. They hunted—and sometimes came back empty handed. They dug and climbed and rooted around and gathered. They walked, ran, stalked, jumped, lifted. Movement was a necessity.

In short, they experienced energy deficits on a regular basis. And energy deficits, particularly sustained energy deficits, are the primary triggers for autophagy. Without energy deficits, you remain in fed mode and never quite hit the fasted mode required for autophagy.

Now compare that ancestral food environment to the modern food environment:

Almost no one goes hungry. Food is cheap and plentiful, with the tastiest and most calorie-rich stuff tending to be the cheapest and most widely available.

Few people have to physically work for their food. We drive to the store and walk a couple hundred steps, hand over some money, and—BOOM—obtain thirty thousand calories, just like that. Or someone comes to our house and delivers the food directly.

We eat all the time. Unless you set out to do it, chances are you’ll be grazing, snacking, and nibbling throughout the day. We’re in a perpetually fed state.

The average person in a modern society eating a modern industrial diet rarely goes long enough without eating something to trigger autophagy. Nor are they expending enough energy to create an energy deficit from the other end—the output. It’s understandable. If our ancestors were thrust into our current situation, many would fall all over themselves to take advantage of the modern food environment. But that doesn’t make it desirable, or good for you. It just means that figuring out how to trigger autophagy becomes that much more vital for modern humans.

Here are 7 ways to induce autophagy with regular lifestyle choices.

1) Fast

There’s no better way to quickly and reliably induce a large energy deficit than not eating anything at all. There are no definitive studies identifying “optimal” fasting guidelines for autophagy in humans. Longer fasts probably allow deeper levels of autophagy, but shorter fasts are no slouch.

2) Get Keto-Adapted

When you’re keto- and fat-adapted, it takes you less time to hit serious autophagy upon commencing a fast. You’re already halfway there.

3) Train Regularly

With exercise-related autophagy, the biggest effects are seen with lifelong training, not acute. In mice, for example, the mice who are subjected to lifelong exercise see the most autophagy-related benefits. In people, those who have played soccer (football) for their entire lives have far more autophagy-related markers of gene activity than people of the same age who have not trained their whole lives.

4) Train Hard

In studies of acute exercise-induced autophagy, the intensity of the exercise is the biggest predictor of autophagy—even more than whether the athletes are in the fed or fasted state.

5) Drink Coffee

At least in mice, both caffeinated and decaffeinated coffee induce autophagy in the liver, muscle tissue, and heart. This effect persists even when the coffee is given alongside ad libitum food. These mice didn’t have to fast for the coffee to induce autophagy.

Certain nutrients can trigger autophagy, too….

6) Eat Turmeric

Curcumin, the primary phytonutrient in turmeric, is especially effective at inducing autophagy in the mitochondria (mitophagy).

7) Consume Extra Virgin Olive Oil

The anticancer potential of its main antioxidant, oleuropein, likely occurs via autophagy.

Disclaimer: The autophagy/nutrient literature is anything but definitive. Most studies take place in test tube settings, not living humans. Eating some turmeric probably won’t flip a switch and trigger autophagy right away, but it won’t hurt.

Autophagy is a long game.

This can’t be underscored enough: Autophagy is a lifelong pursuit attained by regular doses of exercise and not overeating every time you sit down to a meal. Staying so ketotic your pee tests look like a Prince album cover, doing epic 7-day fasts every month, fasting every other day, making sure you end every day with fully depleted liver glycogen—while these strategies might be “effective,” obsessing over their measures to hit some “optimal” level of constant autophagy isn’t the point and is likely to activate or trigger neurotic behavior.

Besides, we don’t know what “optimal autophagy” looks like. Autophagy isn’t easy to measure in live humans. You can’t order an “autophagy test” from your doc. We don’t even know if more autophagy is necessarily better. There’s the fact that unchecked autophagy can actually increase existing cancer in some cases. There’s the fact that too much autophagy in the wrong place might be bad. We just don’t know very much. Autophagy is important. It’s good to have some happening. That’s what we have to go on.

Putting These Tips Into Practice

Autophagy happens largely when you just live a healthy lifestyle. Get some exercise and daily activity. Go hard every now and then. Sleep deeply. Recover well. Don’t eat carbohydrates you don’t need and haven’t earned (and I don’t just mean “earned through glycogen depleting-exercise”). Reach ketosis sometimes. Don’t eat more food than you need. Drink coffee, even decaf.

All those caveats aside, I see the utility in doing a big “autophagy session” a few times a year. Here’s how mine looks:

  1. Do a big training session incorporating strength training and sprints. Lots of intense bursts. This will trigger autophagy.
  2. Fast for two or three days. This will push autophagy even further.
  3. Stay busy throughout the fast. Take as many walks as possible. This will really ramp up the fat burning and get you quickly into ketosis, another autophagy trigger.
  4. Drink coffee throughout the fast. Coffee is a nice boost to autophagy. Decaf is fine.

I know people are often skeptical of using “Grok logic,” but it’s likely that most human ancestors experienced similar “perfect storms” of deprivation-induced autophagy on occasion throughout the year. You track an animal for a couple days and come up short, or it takes that long to make the kill. You nibble on various stimulants plucked from the land along the way. You walk a ton and sprint some, then lift heavy. And finally, maybe, you get to eat.

If you find yourself aging well, you’re on the right track. If you’re not progressing from obesity to diabetes, you’re good to go. If you’re maintaining and even building your muscle despite qualifying for the blue plate special, you’ve probably dipping into the autophagy pathway. If you’re thinking clearly, I wouldn’t worry. Obviously, we can’t really see what’s happening on the inside. But if everything you can verify is going well, keep it up.

That’s it for today, folks. If you have any more questions about autophagy, leave them down below and I’ll try to get to all of them in future posts.

Thanks for reading!

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References:

Yang ZJ, Chee CE, Huang S, Sinicrope FA. The role of autophagy in cancer: therapeutic implications. Mol Cancer Ther. 2011;10(9):1533-41.

Barlow AD, Thomas DC. Autophagy in diabetes: ?-cell dysfunction, insulin resistance, and complications. DNA Cell Biol. 2015;34(4):252-60.

Sasaki Y, Ikeda Y, Iwabayashi M, Akasaki Y, Ohishi M. The Impact of Autophagy on Cardiovascular Senescence and Diseases. Int Heart J. 2017;58(5):666-673.

Florencio-silva R, Sasso GR, Simões MJ, et al. Osteoporosis and autophagy: What is the relationship?. Rev Assoc Med Bras (1992). 2017;63(2):173-179.

Li Q, Liu Y, Sun M. Autophagy and Alzheimer’s Disease. Cell Mol Neurobiol. 2017;37(3):377-388.

Jiao J, Demontis F. Skeletal muscle autophagy and its role in sarcopenia and organismal aging. Curr Opin Pharmacol. 2017;34:1-6.

Schwalm C, Jamart C, Benoit N, et al. Activation of autophagy in human skeletal muscle is dependent on exercise intensity and AMPK activation. FASEB J. 2015;29(8):3515-26.

De oliveira MR, Jardim FR, Setzer WN, Nabavi SM, Nabavi SF. Curcumin, mitochondrial biogenesis, and mitophagy: Exploring recent data and indicating future needs. Biotechnol Adv. 2016;34(5):813-826.

Przychodzen P, Wyszkowska R, Gorzynik-debicka M, Kostrzewa T, Kuban-jankowska A, Gorska-ponikowska M. Anticancer Potential of Oleuropein, the Polyphenol of Olive Oil, With 2-Methoxyestradiol, Separately or in Combination, in Human Osteosarcoma Cells. Anticancer Res. 2019;39(3):1243-1251.

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The Real Deal On Keto Body Odor

I’m continuing my crusade of keto mythbusting. Recently, there was keto crotch, then keto bloat, and today I’m returning to one of the O.G. myths—keto body odor. Yes, it seems detractors of the keto diet are hell-bent on making you think your body will become a stinky, bloated mess if you dare to drop your carbs below 50 grams per day…but is it true?

Here’s the spoiler: Yes, people in online keto diet forums occasionally complain about an unpleasant change in body odor when they first go keto. There is no scientific evidence that it actually happens, nor a clear, compelling explanation for why it would. Moreover, the anecdotal (and it’s all anecdotal) evidence suggests that if it does occur, it is rare and temporary. In other words, the whole idea of keto body odor seems to be exaggerated—shocking, I know.  

That said, significant dietary changes can result in other physiological changes that may manifest in a variety of ways. Since nobody wants to be the stinky kid, let’s take this opportunity to look at what might be plausible about keto body odor and what to do if you think you’ve been afflicted.  

What Causes Body Odor?

First, let’s clarify what’s meant by “body odor.” In the medical literature, the term is used in reference to aromas associated with breath, urine, feces, vaginal secretions, sweat (usually from the axilla, or armpits), and general bodily essence as it were. Because it’s such a broad term, the causes are also extremely varied. For the purposes of this post, I’m going to use the term “body odor” to mean aromas from sweat and general bodily funk, since that’s what’s usually meant by keto body odor.

Body odor arises when odorless compounds leave the body through glands in the skin and interact with microbes living on the skin’s surface. The microbes then release chemical compounds—what we actually detect as body odor. Typically, commercial deodorants target both pieces of the equation by using antiperspirants to minimize the excretion of the odor precursors and by creating an unfavorable environment for the microbes living on the skin. There is also a genetic component to how much individuals secrete compounds that cause body odor.

Although a huge industry is built around trying to help people mask their natural odors—and suggesting that body odor is always the result of poor hygiene—bodily scents are actually quite important. Just as other animals do, humans use olfactory cues for recognizing kin, making judgments about others’ personality traits and attractiveness, and even for detecting fertility. Although we rarely recognize it, the data suggests that smell probably factors into all our face-to-face social interactions.

Body odor can also result from illness. Before the use of sophisticated modern disease detection techniques, doctors were taught to use their sniffers as a diagnostic tool. Even today, smell can be an important clue that an individual is unwell. Often these odors emanate from the breath or urine, but certain infectious and metabolic diseases can be associated with distinctive body odors. In addition to perceptible body odor, the human olfactory system can detect infection and sense illness in others, presumably an important means of preventing the spread of communicable disease.

Diet and Body Odor

The whole notion that a keto diet can cause body odor rests on the assumption that how we smell is affected by what we eat. It turns out that there is scant evidence that that is actually the case.

When I’ve taken up the question of keto diet and body odor previously, I noted that there are really only two human studies that speak to this. One small study found that women judged men’s body odor more negatively when they ate a diet that contained red meat compared to when they abstained from red meat. However, the diets differed in other ways as well. In contrast, a different study found that women rated men’s body odor more positively when the men reported eating more fat, meat, and eggs, and more negatively when they ate more carbs. Hmm.  

Besides those two small studies, evidence that diet impacts body odor seems to come primarily from studies on guinea pig urine and meadow voles—not exactly the most compelling in my opinion.

Nevertheless, the common belief persists that certain foods will make you stinky: garlic, onions, cruciferous vegetables, and spicy foods especially. However, there is no evidence that this is actually the case beyond the obvious bad breath and, ahem, flatus that these foods can cause. In fact, the one study I found on the subject reported that garlic counterintuitively improved body odor.

So, Can Keto Make You Stinky?

As you can see, there’s minimal evidence at best linking body odor to diet, and none of it has to do with the keto diet itself. Nevertheless, the belief that keto causes body odor persists…thanks to the few complaints from some in the keto community (and, just maybe, those who have nothing to do with keto but want to cause a stir). While I don’t want to dismiss anecdotal evidence out of hand, I have noticed that once people go keto, their diet is immediately to blame for every weird smell, twitch, or symptom. It’s remarkable really.

In the interest of fairness, let’s look at the explanations that are typically offered for why keto might cause body odor:

Is It the Protein?

The first hypothesis is that keto dieters smell funky because they’re eating a lot more meat. As I already mentioned, there are only two small studies that speak to this, and the findings conflict. The idea at work: protein metabolism yields ammonia as a byproduct (true), which builds up because of eating “too much protein,” resulting in body odor.  

To which I object… First of all, it’s not necessarily true that going keto means eating more meat. My version of a keto diet certainly isn’t a steak-and-bacon fest—I still eat tons of veggies. If anything, my observation is that keto folks by and large remain fearful of eating “too much” protein lest it kick them out of ketosis. (The issue is not nearly so simple as that, as I’ve explained.) In any case, even if you’re eating a good deal of meat, a healthy liver should be able to convert the amount of ammonia generated into urea and send it off to the kidneys to be excreted as urine.

Maybe It’s the “Detoxing”?

Toxins such as environmental pollutants accumulate in adipose tissue, a.k.a. fat cells, and these toxins are then released into the bloodstream when people burn fat. Because the keto diet often results in increased burning of body fat, the theory goes that the body is “detoxing” all these pollutants, and that’s what causes body odor. Detoxing is a controversial subject, and while it is true that some of these toxins can be excreted through the skin, the actual amounts are fairly small (the majority get excreted via urine and feces). Plus, it’s not evident that the toxins that are excreted through the skin cause any particular odor. And wouldn’t any diet that actually does what it’s supposed to—i.e. burn fat—be subject to the same “stinky” detox effect? I think we can safely chuck this claim.

Are Ketones a Cause?

Maybe ketones themselves make you smelly? This one has the most potential validity, as it’s well documented that acetone—one of the three ketone bodies—gets excreted when you’re in ketosis. However, it’s the cause of the familiar keto breath, not body odor per se. I’ve seen no evidence linking acetone to actual body odor.

What To Do About It

Ok, I hear you saying, “Mark, I see that you’re skeptical, but I’m telling you… I stink!” What can you do about it?

Well, since there isn’t a clearcut cause, I can’t give a clearcut answer, but I’ll tell you what the general wisdom says:

First, you can support your body’s own detoxification pathways as I describe here. Your body should be able to do a fine job taking out the garbage—it’s designed to do so and is efficient at it—but hey, why not drink some coffee and throw some broccoli sprouts on your salad. This is a “can’t hurt, might help” situation.

Same thing goes for taking some nice epsom salt baths, another common recommendation. Whether there is any truth to their detoxifying nature, you’ll get a nice dose of transdermal magnesium with a hefty side of relaxation. Throw in some essential oils and olive oil and soak your cares away… hopefully taking some of the b.o. with it.

You can also experiment with eating less protein and more carbs, but I do see potential downsides to both. You definitely don’t want to eat too little protein, since it serves such a vital role in healthy functioning, and you don’t want to add back too many carbs if being in ketosis is your goal. That said, especially with regard to the protein you probably have room to play around, so feel free to experiment if you want. I’m not overly optimistic that this is the answer, but I’m always a fan of finding what works for you.  

Or, take a wait and see approach. Most keto side effects come and go as people become keto-adapted. If your problem is keto breath, not body odor per se, you can try chewing on some fresh herbs or taking chlorophyll supplements, but these will just mask the issue.

Lastly, if it is very noticeable and very bothersome, you can—and probably should—consult your doctor. If you are excreting significant ammonia, which usually happens via the breath, this is a sign of liver or kidney problems that need to be diagnosed asap.

The Bottom Line…

Because switching to a keto diet can initiate a profound metabolic shift, some people might experience side effects. And, sure, it’s conceivable that transient changes to body odor might be one of them. The lack of evidence that body odor is strongly affected by diet (as well as my own experience interacting with the thousands of people in my community who have tried keto) leads me to believe that this is a minor problem at most—and one that most people won’t experience at all. If it’s affecting you, feel free to try to solutions I described above. They might not resolve the problem immediately, but at least they’ll likely have other positive benefits.

Ok, what say you? Are your friends giving you a wide berth now that you’re in ketosis, or are you chalking this up to yet another thing the haters are blowing out of proportion?

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References:

Groyecka A, Pisanski K, Sorokowska A, et al. Attractiveness Is Multimodal: Beauty Is Also in the Nose and Ear of the Beholder. Front Psychol. 2017;8:778.

James AG, Austin CJ, Cox DS, Taylor D, Calvert R. Microbiological and biochemical origins of human axillary odour. FEMS Microbiol Ecol. 2013 Mar;83(3):527-40.

Natsch, A. What Makes Us Smell: The Biochemistry of Body Odour and the Design of New Deodorant Ingredients. CHIMIA Intl J Chem. 2015 Aug;69(7-8):414-420.

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Keto Bloat: Separating Fact from Fiction

Move over, keto crotch. There’s a new fear-mongering anti-keto media blitz forming: keto bloat.

According to the “good scientists” of the Kellogg company food lab, an unprecedented number of young people are walking around with bloated guts and colons packed to the brim with impacted fecal matter, and it’s all because they’ve embraced ketogenic diets and “forsaken” fiber.

If this sounds like nonsense, that’s because it is.

Are millions of keto dieters suffering from bloating and constipation? I can find no evidence of this.

Is fiber necessary to prevent bloating and constipation? It’s complicated. I’ll explain later. But probably not.

Does the ketogenic diet necessarily exclude fiber? Not at all.

Are ketogenic diets as commonly practiced low in fiber? No.

What Is “Bloat” Anyway?

There are two things that people refer to as bloat: constipation and abdominal distension.

Constipation has different components. It’s being unable to make a satisfying bowel movement. It’s also feeling like you have to poop but are unable to. It’s being able to poop only a little bit. It’s struggling on the toilet bowl. Mostly, it’s being unhappy with your performance on the toilet.

Abdominal distension also can be different things. It might be trapped gas. It might be feeling “heavy” or “full.” It might mean your pants don’t fit after eating.

So, “bloating” can be any or all of these. You can pass hard small stools and feel like you’re bloated. You can poop just fine but have a lot of gas and feel like you’re bloated. You can spend hours on the toilet with not much to show for your effort and be bloated. So “Keto bloat” is difficult to pin down. That makes it easy to make claims and hard to disprove.

Let’s see how frequent bloating and constipation occurs in the ketogenic diet literature.

What Does Research Say About Constipation?

In a study of children with epilepsy placed on an olive oil-based ketogenic diet, about 25% of the subjects experienced constipation. So, was ketosis slowing them down? Not exactly. Those who experienced constipation were actually less likely to be in ketosis. Constipation went up as ketone readings went down, and epilepsy symptoms returned. Constipation improved as ketone readings went up and epilepsy symptoms subsided.

In adults with epilepsy on a ketogenic diet, constipation occurred in just 9% of patients. The authors note that this rate is lower than some other ketogenic studies and attribute the difference to “the heavy focus on importance of fiber from nutrient dense (fiber rich) vegetables, nuts, and seeds.” Note that they weren’t getting fiber from pills and powders. They were eating nutrient-dense foods that just so happened to contain fiber.

Another ten-year study compared the classical ketogenic diet, MCT oil-based ketogenic diet, and modified Atkins keto diet. They were all equally effective at reducing epilepsy symptoms in children, but the occurrence of constipation varied greatly. It was most common in the classic keto diet and medium chain triglyceride-based diet, both of which restrict protein. In the modified Atkins diet, which does not restrict protein, constipation was much rarer. Another study on the modified Atkins diet had similar results, with just 2 of 26 subjects reporting constipation.

Constipation does seem to be a common occurrence. However, the majority of keto diet studies are in epileptic populations following very strict clinical Keto diets. The extreme nature of these therapeutic ketogenic diets—extreme protein (7% of calories) and carbohydrate restriction—makes them an imperfect representation of how most people are eating Keto. And in studies of less-extreme, more realistic versions of the diet, such as modified Atkins (which allows more protein) or the version with “heavy focus” on vegetables, nuts, and seeds, constipation occurs at a much lower rate.

What Does Research Say About Bloating?

The only instance of something approximating bloating in the ketogenic diet literature occurred in studies using medium chain triglyceride-based diets. These are ones that use huge amounts of MCT oil to increase production of ketone bodies. It works great for curbing epilepsy symptoms, but it can also cause cramping, diarrhea, and abdominal pain. That’s not bloating per se. It’s literally the closest I could find.

Causes Of Bloating While Keto?

Okay, say you are dealing with constipation or bloating on a keto diet. What could be going on?

Not Enough Food

Constipation is often a consequence of low energy status. Everything that happens in the body requires energy, and if energy levels are low or energy availability is poor, basic functions will suffer. Bowel movements are no exception. The muscles and other tissues responsible for moving things along your digestive tract use energy. If you aren’t providing adequate amounts of energy, you’re depriving your tissues of the ATP they need to work best and sending your body a signal of scarcity which will only depress energy expenditure even more.

Low carb diets in general and keto diets in particular are very good at causing inadvertent calorie reduction. Great for fat loss, but some people take it overboard and go too far. I’m talking 800-1000 calories a day on top of CrossFit. That’s a recipe for disaster.

Water and Mineral Loss

When you go Keto for the first time, you shed tons of water. For every gram of glycogen you lose, you drop 3-4 grams of water. You also lose sodium and potassium with the water, and you need extra magnesium to regulate your sodium and potassium levels.

The water content of stool is what gives it that smooth texture we all desire. If you’re dehydrated, even mildly, you’ll have less water available for your bowel movements and be more likely to suffer from constipation.

Drink a big glass of salty water with lemon juice in the morning and sip on salty broth throughout the day. Zucchini is a great source of potassium, as is avocado.

Also, if you’re going to eat more fiber, you need to increase water intake for it to work.

Too Much or Too Little Fiber

The relationship between fiber and constipation is mixed. Some interventions do seem to help. Psyllium husk and flaxseed have both been shown to improve constipation. Galactooligosaccharides, a class of prebiotic fiber, improve idiopathic constipation. And inulin, another prebiotic fiber, improves bowel function and stool consistency in patients with constipation.

But there’s also evidence that more fiber can make the problem worse. In one 2012 study, patients with idiopathic constipation—constipation without apparent physiological or physical causes—had to remove fiber entirely to get pooping again. Those who kept eating a bit or a lot of it continued to have trouble evacuating. The more fiber they ate, the worse their constipation (and bloating) remained. Another review found mixed evidence; some people get less bloating and constipation with more fiber, others get less bloating and constipation with less fiber.

Personally, my toilet performance is stellar with or without a constant intake of voluminous levels of plant matter. Most days I eat a good amount—Big Ass Salads, broccoli, sautéed greens, berries—but on the days I don’t, I don’t notice any difference. I’m suspicious of the widespread calls for bowel-rending levels of fiber as the universal panacea for all things toilet, and I’m also suspicious of the people who claim fiber is unnecessary or even harmful.

Fiber helps some people and hampers others. There’s no one-size-fits-all with fiber, especially since there are many different types of fiber.

Too Many Sugar Substitutes

I get it. There are some interesting candies out there that cater to the Keto set and use various sugar alcohols—non-alcoholic, low-or-no calorie versions of sugar—artificial sweeteners, and fibers to recreate popular treats. It’s fun to eat an entire chocolate bar that tastes pretty close to the real thing and get just a few net carbs. But that’s a lot of fermentable substrate your gut bugs are more than happy to turn to gas.

If you want the opposite problem, you can always turn to Haribo sugar-free gummy bears.

FODMAP Intolerance

FODMAPs stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—the carbohydrates in plants that our gut bacteria usually mop up. Most people have gut biomes that can handle FODMAPs; indeed, most people derive beneficial short chain fatty acids from their fermentation. But some people’s gut biomes produce too much fermentation when they encounter FODMAPs. Fermentation begets hydrogen gas, which gathers in the gut and causes great distress. Common complaints of the FODMAP intolerant are bloating, stomach pain, and visits to the toilet that are either unproductive or way too productive—all of which fall into the bloating category.

The myth is that Keto people are eating salami and cream cheese for every meal. The reality is that many people go Primal or Keto and find they’re eating way more vegetables than they ever have before. These are great developments, usually, but if you’re intolerant of FODMAP fibers, you may worsen the bloating.

What Can You Do?

Eat enough protein. Most people can get away with eating 15-25% of their calories from protein and still stay in ketosis. Most people can eat even more protein and still get most of the benefits of fat-adaptation. The keto studies which had the lowest rates of constipation were far more tolerant of higher protein intakes.

Eat FODMAPs unless you’re intolerant. Most people can eat FODMAPs. In most people, FODMAPs improve gut health and reduce constipation and bloating. But if your gut blows up after a few bites of broccoli or asparagus, consult the FODMAPs list and try a quick FODMAP elimination diet.

Make sure you’re truly constipated. Your stool volume and frequency of toilet visits will decline on a normal ketogenic diet because there’s less “waste.” Make sure you’re not misinterpreting that as constipation or bloating. If there’s less poop, there’s less poop. If there’s more poop but it’s just not coming, and you have to go but can’t, that’s when you have an issue.

Experiment with fiber. Fiber clearly has a relationship to bloating and constipation. You just have to figure out what that looks like in your diet.

  • If you’re bloated and constipated on a high-plant Keto Diet, eat fewer plants.
  • If you’re bloated and constipated on a low-plant Keto Diet, try eating more plants. If that doesn’t help, go zero-plant.
  • If you’re bloated and constipated on a zero-plant Keto Diet, try eating more plants. .

We all have to find our sweet spot.

So, to sum up, “keto bloat” is mostly a myth. There’s a glimmer of truth there, but it’s highly exaggerated. Constipation is common on the most restrictive clinical keto diets, while eating fiber from whole plant foods, being less restrictive with protein, and making sure you’re drinking enough water and eating enough calories and electrolytes seems to avoid the worst of it.

What’s been your experience with bloating and constipation? How have you handled it?

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References:

Ho KS, Tan CY, Mohd daud MA, Seow-choen F. Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms. World J Gastroenterol. 2012;18(33):4593-6.

Müller-lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005;100(1):232-42.

Guzel O, Uysal U, Arslan N. Efficacy and tolerability of olive oil-based ketogenic diet in children with drug-resistant epilepsy: A single center experience from Turkey. Eur J Paediatr Neurol. 2019;23(1):143-151.

Roehl K, Falco-walter J, Ouyang B, Balabanov A. Modified ketogenic diets in adults with refractory epilepsy: Efficacious improvements in seizure frequency, seizure severity, and quality of life. Epilepsy Behav. 2019;

Liu YM. Medium-chain triglyceride (MCT) ketogenic therapy. Epilepsia. 2008;49 Suppl 8:33-6.

Arnaud MJ. Mild dehydration: a risk factor of constipation?. Eur J Clin Nutr. 2003;57 Suppl 2:S88-95.

Noureddin S, Mohsen J, Payman A. Effects of psyllium vs. placebo on constipation, weight, glycemia, and lipids: A randomized trial in patients with type 2 diabetes and chronic constipation. Complement Ther Med. 2018;40:1-7.

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The Curious Phenomenon of “Keto Crotch”

I have a confession to make: I, Mark Sisson, suffer from keto crotch.

It’s embarrassing, really. I thought maybe it was just the change in climate moving from Malibu to Miami—the humidity, the heat, the fact that I’m paddling and swimming more often now. There’s a whole lot of moisture down there. Perpetual steaminess.

But then I met up with my writing partner and good pal Brad Kearns, who’s been working with me on my upcoming book. Brad lives in Northern California, which is far from hot or humid right now. He’s also a staunch keto guy most of the time, and, well, let’s just say I could smell him before I could see him. We met up at a coffee shop and cleared out everyone in a fifteen foot radius. We sampled a new exogenous ketone product he’s been trying and not one, not two, but three separate individuals approached to inquire if we were salmon fishermen.

Okay, let’s get serious. Does “keto crotch” really exist? And, if it does, what can you do to prevent it?

I’m writing this not because of overwhelming demand from loyal followers of the Keto Reset plan. In fact, I hadn’t ever heard of “keto crotch” before last week. There’s a good chance almost no one heard of it before March 2019, if Google Trend data for “keto crotch” searches is any indication. I’m writing this post because the barrage of news articles, Twitter hashtag campaigns, and extremely serious warnings from people with lots of acronyms after their name has led people to ask me if it’s a legitimate phenomenon. A few acquaintances have brought it up in social situations. Our marketing director found herself fielding keto crotch questions at a dinner for Expo West last week.

So, are women following a ketogenic diet experiencing an epidemic of stinky vaginas?

Probably not.

Is Keto Crotch Even Physiologically Plausible?

Vaginal odor does change. It fluctuates naturally, and sometimes it can get worse. The most common cause of unpleasant changes to vaginal odor is bacterial vaginosis, which occurs when something upsets the balance between the beneficial lactobacilli bacteria that normally live in the vagina and pathogenic bacteria. What can upset the balance?

The vagina is supposed to be an acidic environment; that’s how the healthy lactobacilli thrive. If something upsets that pH balance, tilting it toward alkalinity, unhealthy bacteria gain a foothold and become predominant, and begin producing unpleasant-smelling amines like putrescine, tyramine, and cadaverine. This is bacterial vaginosis. As it turns out, the lactobacilli bacteria normally present in the vagina are instrumental in maintaining an acidic pH. They consume glycogen, spit out lactic acid, and exert antimicrobial and antifungal effects that block common vaginal pathogens like candida, e. coli, and gardnerella from taking hold and causing trouble.

The interaction between diet and vaginal biome is understudied. To my knowledge, there exist no direct controlled trials that address the issue. It’d be great to have a study take a cohort of women, split them up into different dietary groups, and follow them for a year,  tracking their vaginal pH and bacterial levels. Alas, we do not.

We do have a study that provides a hint. In 2011, researchers looked for correlations between dietary patterns and bacterial vaginosis in a cohort of nearly 2000 non-pregnant mostly African-American women aged 15-44. While there probably weren’t many keto dieters, and the diets as a whole were of the standard American variety, glycemic load—which basically boils down to carb load—was the strongest predictor of bacterial vaginosis. Other markers of food quality, like a person’s adherence to “healthy eating guidelines,” initially seemed to reduce the chance of bacterial vaginosis, but those relationships were almost abolished after controlling for other factors. Only glycemic load remained highly significant.

This connection between dietary glycemic load and bacterial vaginosis starts looking more causal when you realize that diabetes—a disease where one’s “glycemic load” is perpetually elevated and exaggerated—is another risk factor for bacterial vaginosis.

There’s also a 2007 study that found “high” intakes of dietary fat, particularly saturated and monounsaturated fat, were a significant predictor of bacterial vaginosis. In this study, “high fat” meant around 39% of energy from fat. That leaves 61% of energy from carbohydrate and protein, the kind of “high-fat, high-carb” Standard American No-Man’s-Land that’s landed the country in the current metabolic predicament. High-fat intakes in the presence of high-carb intakes may very well be bad for your vagina, but it says nothing about the likelihood of keto crotch.

At any rate, neither study was a controlled trial, so we can’t say anything about causality.

What about a yeast infection? The most common offender is candida, which usually favors sugar for fuel, but there’s also evidence that it can metabolize ketones. Could keto make a latent yeast infection worse and lead to smelly “keto crotch”?

Perhaps keto can make candida worse (that’s for another day), but that’s not the cause of “keto crotch.” Candida vagina infections don’t smell very much, if at all, and they certainly don’t smell “fishy.” That’s only caused by bacteria and the aforementioned amines they can produce.

Free glycogen levels in vaginal fluid are a strong predictor of bacterial vaginosis. If ample glycogen is available, the good lactic acid bacteria have plenty of food and produce plenty of lactic acid to maintain the acidic pH conducive to vaginal health. If inadequate glycogen is present, the lactic acid bacteria have less food and produce less lactic acid, increasing the chances of the pH tilting toward alkalinity. An alkaline vagina is a vagina where pathogenic bacteria—the ones that produce stinky amines—can establish themselves.

The question then is if ketogenic diets lower free glycogen in the vaginal fluid. That’s a fair question. I wasn’t able to find any solid answers. I guess “ketosis effect on vaginal glycogen” isn’t the most lucrative avenue of scientific inquiry.

Should I Worry?

Even assuming this is a real phenomenon, it’s a rare one. The vast, vast majority of people following a ketogenic diet aren’t coming down with keto crotch. Other than a few Reddit posts from the past 5 years, I haven’t seen anyone at all in our neck of the woods complain.

Maybe people doing Primal keto are eating more nutrient-dense ketogenic diets than people doing conventional (or caricature) keto. Salads, steaks, eggs, and lots of non-starchy veggies are a great way to stay keto and obtain micronutrients. And there are links between micronutrient status and bacterial vaginosis. The most common relevant deficiencies include vitamin D (correcting the deficiency can cure the vaginosis) and folate. Hard to get adequate folate if your diet is based on salami and cream cheese.

We also know that the health of your skin biome tracks closely with that of your gut, and that eating plenty of non-starchy veggies, fermented foods (yogurt, kefir, sauerkraut, kimchi, etc), and colorful produce can provide prebiotic fiber, prebiotic polyphenols, and probiotic bacteria that nourish your gut biome. If the vaginal biome is also connected to the gut biome (and it is), tending to the latter should also have positive effects on the former.

The Primal brand of keto tends to emphasize micronutrients and gut health a bit more than some other types of keto I see floating around. If—and it’s a very big “if”—keto crotch is legit, that may explain some of the discrepancy.

Finally, be sure to check out this very interesting Twitter thread where the author lays out his suspicions that the whole “keto crotch” phenomenon might be a manufactured stunt designed to vilify the ascendant ketogenic diet. Nothing definitive, but it’s certainly food for thought.

If You’re Concerned…

Okay. Say you’ve recently gone keto and your vagina is smellier than usual. (And you’ve ruled out other, more obvious potential causes like changes in soaps, etc.) It’s hard to ignore, and I wouldn’t want you to. What can you do?

  • Confirm that you have bacterial vaginosis. Seriously, get it checked out.
  • Make sure you’re getting enough folate and vitamin D. Supplement if need be.
  • Eat prebiotics and probiotics. Fermented food and/or a good probiotic supplement.
  • Try a carb refeed. If ketosis depletes vaginal glycogen and increases pH, the occasional carb refeed could restore glycogen by 30-50 grams and should do the trick. Note that this is entirely theoretical; I’m not saying it’s a “problem” on keto.
  • Hang out in the keto zone. I’ve written about the keto zone—that metabolic state where you’ve reached full keto and fat-adaptation and find yourself shifting in and out of ketosis as you please due to increased metabolic flexibility. A few carbs here, a fasting day there, a few more days of keto. Again, if full keto is theoretically depleting vaginal glycogen, maybe relaxing your restrictions will solve the issue while maintaining your fat adaptation. This is actually where I hang out most of the time.

That’s it for today, folks. Do you have “keto crotch”? Do you know anyone who does? Or did your vaginal health improve on keto? I’m curious to hear what everyone’s experiences have been, so don’t be shy.

Take care and be well.

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References:

Thoma ME, Klebanoff MA, Rovner AJ, et al. Bacterial vaginosis is associated with variation in dietary indices. J Nutr. 2011;141(9):1698-704.

Kalra B, Kalra S. Vulvovaginitis and diabetes. J Pak Med Assoc. 2017;67(1):143-145.

Taheri M, Baheiraei A, Foroushani AR, Nikmanesh B, Modarres M. Treatment of vitamin D deficiency is an effective method in the elimination of asymptomatic bacterial vaginosis: A placebo-controlled randomized clinical trial. Indian J Med Res. 2015;141(6):799-806.

Dunlop AL, Taylor RN, Tangpricha V, Fortunato S, Menon R. Maternal vitamin D, folate, and polyunsaturated fatty acid status and bacterial vaginosis during pregnancy. Infect Dis Obstet Gynecol. 2011;2011:216217.

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4 Misunderstandings About Carbs and Stress

The relationship between stress and carbohydrates is confusing, with seemingly contradictory arguments bouncing around the online health sphere.

There are those who say high-carb diets cause stress, and that eating more fat and fewer carbs is the solution.

There are those who say high-fat diets increase stress and eating carbs ameliorates it.

Who’s right? They can’t both be right, can they?

Well…

You’d be surprised.

Let’s dig into four common carb questions and assertions.

“Stress Increases Carb Cravings.”

This is well-established. You have a terrible day at the office, your kids have appointments twenty miles apart within fifteen minutes of each other, the traffic is backed up to your driveway, you’re late for work, the dog needs a walk, you haven’t even thought about what to make for dinner, you slept four hours last night—it adds up. People deal with a lot. And in that moment, a carbohydrate-based snack really does seem to take the edge off.

Across millions of years of hominid evolution, the human stress response developed in the context of real-world, short-term, and infrequent but intense stressors: battles, hunts, freak injuries, dangerous animal encounters, interpersonal conflicts. These were situations that demanded heightened senses, available fuel, and a rapid heart rate to deliver everything to the tissues that needed to move and act. It makes perfect sense for your body to pump out adrenaline to increase fat burning and glucose in the blood—you need that fuel to deal with the situation. It also makes sense for your body to follow that up with a blast of cortisol, which makes you crave high-carb junk food to replace the fuel you utilized. The problem is that our modern stressors are too frequent, they aren’t physically demanding, we aren’t utilizing the fuel we mobilize, and we have no real need for the carb cravings that come after.

What happens when we eat too many carbs that we never actually needed?

We get fat. Cellular energy supply becomes overloaded, impairing our mitochondria’s ability to process energy efficiently. This degrades metabolic flexibility—the ability to switch between different fuel sources—preventing us from burning the fat on our bodies in between meals. We become reliant on those carbs, and when we don’t get them fast enough, our bodies perceive that as a major stressor.

So while giving in to carb cravings can reduce stress in the short-term, it sets us up for longer-term, more chronic stress.

“What About Gluconeogenesis? Isn’t That a Stress Response?”

It can be.

A primary goal of cortisol is to increase glucose availability. It does this through multiple avenues. One I just mentioned is to increase carb cravings. Another is to make you insulin resistant, thereby preventing insulin from sucking up blood glucose. Gluconeogenesis—the creation of glucose from amino acids and other substrates—is another.

If you’re a sugar-burner, stressful situations will increase carb cravings, induce gluconeogenesis, and may even make you insulin resistant. If you’re fat-adapted, the story shifts.

A fat-adapted person will have ketones and fatty acids available to provide energy in between meals. A fat-adapted person will have ketones and fatty acids available to provide energy in stressful situations. A fat-adapted person will be able to utilize those ketones and fatty acids during stressful situations—their mitochondria will literally be primed to utilize those fuels, not just glucose. A fat-adapted person is less likely to perceive carbohydrate shortages as stress shortages because they’ve got all this other fuel available to burn.

This adaptation doesn’t happen overnight. If your diet is low-carb or keto, but your body is still reliant on sugar, you will perceive reduced carb availability as a stressor. That’s one of the hallmarks of the keto flu, and it’s one reason why some people have extended keto flu—their bodies are still expecting and demanding glucose.

Some people never get over the carb cravings; they never fully adapt. This is the subset of the population that doesn’t function or perform well on a long-term ketogenic diet. The cause is unknown, at least for now (I suspect it has to do with recent ancestry and genetic proclivities), but what matters is that these people exist. For them, a long-term keto or very low carb diet approach will probably always be stressful. But even in these folks, spending some time in ketosis—through short term low-carb eating, intermittent fasting, or even extended low-level endurance activity that primarily burns fat—is a good idea that will reduce stress and improve overall resilience.

“But Carbs Make Exercise Less Stressful!”

Exercise is stressful to begin with. But then you adapt to the stress and overcome it—and end up stronger, fitter, and faster than before. Without the stress, working out doesn’t work. A legitimate method for increasing your work capacity is to train-low (carb), race-high (carb). Athletes have been doing this for decades—training in a low-carb state to get better at performing without ample muscle glycogen, then going into a race with full glycogen reserves and the ability to perform without glycogen. Exercising in that low-glycogen state is stressful, but that’s the whole point. It makes them better, stronger, faster, and it conserves glycogen for when they really need it.

If you consistently perform glucose-intensive high-intensity anaerobic activity for extended periods of time—CrossFit style WODs done 3-5 times per week, for example—you will run up a glucose debt and should replenish some of the carbohydrates you expend or risk cortisol spikes. Fat-adaptation can improve your tolerance of anaerobic activity in a low-glucose state, but there’s a breaking point, a physiological limit.

Eat the carbs you earn. This is a subtle point I don’t often see made. The reverse is widely understood—don’t eat the carbs you don’t earn—because millions of obese and overweight people do that every day. It’s a big reason why we’re so overweight. But if you fail to eat the carbs you earn through intense, protracted physical activity, you’re creating an undeniable glycogen deficiency that your body may perceive as a stressor. It may turn out that fully fat- and keto-adapted athletes can perform intense medium-to-long-term activities at high levels, and there’s some indication that this is the case, but for the time being it appears that eating the carbs you earn can stave off the stress.

“Low-Carb Diets Are Stressful For Women.”

There’s a glimmer of truth here. Allow me to explain.

Women are inherently more sensitive to caloric fluctuations than men…on average. The reason is sheer biology. Human evolution is concerned with fertility and reproduction. Can you produce, foster, and support viable offspring? Awesome. Natural selection deems you fit.

To fulfill their biological role, men have to produce sperm. They can do so almost indefinitely. They don’t run out; they just make more. If a batch is damaged due to poor lifestyle or dietary choices, there’s more on the way. After a man gets someone pregnant, his biological involvement with the growing baby is done. What or when he eats has no impact on the survival of the growing baby.

To fulfill theirs, women have a finite number of eggs, or “chances.” Once an egg is gone, there’s no replacing it.

And so the body seeks to inculcate the egg from environmental insults.

When you are preparing to get pregnant, your body needs extra nutrients to build up a reserve and “prime the pump.”

When you are pregnant, the growing baby needs a reliable and constant stream of nutrients for almost a year.

After you’ve given birth, the growing newborn needs breastmilk. To make that milk requires additional calories and extra doses of specific nutrients. Modern technology allows us to skip nursing and go straight to the bottle, but your body doesn’t “know” that.

It all points to women being more finely attuned to caloric deficits. For example, women’s levels of ghrelin, the hunger hormone, are quicker to rise after meals. Even if you’re never going to have kids, your body is still wired to protect against these caloric fluctuations.

Where do carbs come in?

One’s carbohydrate consumption is uniquely hewed to our sense of caloric sufficiency. If carbs are plentiful, your body perceives that as a signal of environmental plenty: the weather is good, the plants are producing, the trees are bearing fruit, the men are bringing back lots of honey. Life is good. It’s the perfect time to get pregnant. Above all other macronutrients, carbohydrate consumption increases the short-term expression of leptin, a satiety hormone that signals the presence of incoming calories, caloric sufficiency, and environmental plenty.

There’s also the issue of extreme satiety. Low-carb diets often become low-calorie diets without you even trying. That’s why they work so well for fat loss, by inadvertently reducing the amount of food you eat and increasing satiety. But for some women, especially those at or approaching their ideal weight, going too low in calories can increase stress.

Summing Up…

Are you unable to access your own body fat in between meals for energy? Then you’ll be a ball of stress unless you can get those Jolly Ranchers unwrapped quickly enough. It’ll be a constant battle. And yeah, if you keep pumping yourself full of carbs to keep your blood glucose topped off, you’ll keep stress at bay—but you’ll always be teetering on that precipice.

Are you exercising? Then you should strike a balance between gaining the adaptive benefits of training in a low-carbohydrate state and eating the carbs you earn.

Are you a woman? Then you’re probably more sensitive to diet-induced stress and may benefit from occasional carbohydrate refeeds. You should watch out for excessive satiety on ketogenic diets, which is great for fat loss but can lead to stress issues down the line if calories get too low.

The relationship between carbohydrates and stress isn’t exactly straightforward, but it is navigable. Hopefully after today you have a better idea of where you stand in the relationship.

What’s been your experience with stress and carbohydrates? Has your tolerance for stress gone up or down since going low-carb or keto? Thanks for stopping in today.

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References:

Mcallister MJ, Webb HE, Tidwell DK, et al. Exogenous Carbohydrate Reduces Cortisol Response from Combined Mental and Physical Stress. Int J Sports Med. 2016;37(14):1159-1165.

Dirlewanger M, Di vetta V, Guenat E, et al. Effects of short-term carbohydrate or fat overfeeding on energy expenditure and plasma leptin concentrations in healthy female subjects. Int J Obes Relat Metab Disord. 2000;24(11):1413-8.

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