When Should You Try A Low Carb Diet? | Chris Kresser
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When Should You Try A Low Carb Diet?

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Diabetics can thrive on a low-carbohydrate diet. BananaStock/BananaStock/Thinkstock

This is a guest post by Laura Schoenfeld, a Registered Dietitian with a Master’s degree in Public Health, and staff nutritionist for ChrisKresser.com. You can learn more about Laura by checking out her popular blog or visiting her on Facebook. And if you need one-on-one help with your diet, click here to learn more about her nutrition consulting services.

Recently, I wrote an article about the potential pitfalls of following an excessively low carb diet, and the symptoms to watch out for to know if you’d benefit from adding carbs back into your diet. While I repeatedly pointed out that there are many people who thrive on a very low carb or ketogenic approach, there were commenters who staunchly disagreed with my recommendations.

While I stand by my original article (as well as Chris’s subsequent supporting articles here and here), I wanted to make sure that those who would benefit from a very low carbohydrate or ketogenic diet were aware of the positive impact this nutritional approach can have when implemented correctly.

Yes, you read that correctly: there are many people who can do incredibly well on a properly designed, nutritionally adequate ketogenic diet.

Some people find that they thrive on a very low carb or ketogenic diet. Could you be one of them?

In this article, I’ll describe seven different classes of people who could experience improved health and wellbeing by following a ketogenic diet, as well as briefly explain the precautions you’ll need to take if choosing to experiment with this therapeutic diet strategy.

Overweight and Obesity

One of the biggest draws of a low carbohydrate diet is that it can be a highly effective tool for rapid weight loss, especially in those who are significantly overweight and/or obese.

When compared to low fat diets, dozens of studies show that a very low carb approach can be help those who are overweight lose weight, maintain lean muscle mass, and improve many of the metabolic risk factors for diabetes and heart disease, including elevated triglycerides, low HDL, and chronically elevated blood sugar. There’s no denying that a low carb diet can be a highly effective obesity treatment.

Most people believe low carb diets cause weight loss so rapidly by lowering circulating insulin, but another reason why low carb dieting may promote weight loss is because these diets frequently lead to a spontaneous reduction in overall food intake. Combining that with low insulin and high glucagon levels is generally a recipe for immediate weight loss, though this is not always sustainable for a variety of reasons.

The longer a person stays on a low carb diet, the more they may start to find ways to make their diet more palatable, and thus increase their overall calorie intake. Also, as weight loss occurs, a person’s overall calorie expenditure will drop, meaning that the same amount of food that made them lose weight in the first place will eventually cause them to maintain their weight – the dreaded “plateau”.

If you’re eating more calories than you’re expending, even on a low carb diet, you won’t lose weight. If you’re using low carb as a weight loss diet, this doesn’t give you license to eat high fat foods in unlimited quantities. Eat good quality protein, plenty of non-starchy vegetables, and enough fat to meet your daily needs without going overboard and you may find that a nutrient-dense low carb diet is the perfect strategy for sustainable weight loss and reversal of metabolic syndrome.

And remember – obesity is a far different health situation than trying to “lose the last 10 pounds”, so many of the same weight loss principles that work well for people who are significantly overweight may not work so well for those trying to reach their ideal “look good naked” weight. Keep that in mind when considering how much weight you want to lose and whether or not it’s truly necessary for health purposes. Those who don’t really have much excess weight to lose may be more prone to the potential problems with a long term low-carb diet.

Blood Sugar Imbalances

Blood sugar control plays an important part in weight management as well as the prevention of chronic disease, including diabetes, heart disease, cancer, and possibly even Alzheimer’s disease, among others.

If your blood sugar is always elevated, you’re at an exponentially higher risk for dozens of diseases, and you’re more likely to die earlier from these diseases as well. So if you have consistently high blood sugar, you’ll likely find that reducing your carbohydrate intake significantly can bring that number down quickly, particularly if you’re relatively sedentary.

Low carb diets can also be helpful in reactive hypoglycemia, a condition where blood sugar drops too low following a meal, causing symptoms such as dizziness, anxiety, shakiness, hunger, and confusion. This issue can be made worse by caffeine and stress, and I find it more commonly in my clients with adrenal issues.

A common cause of this reaction is when a meal too high in easily absorbed carbohydrates is consumed, and blood sugar rises rapidly, leading to a release of insulin. The insulin causes a subsequent drop in blood sugar, and this drop can sometimes go too low or happen too quickly, leading to the hypoglycemic symptoms.

If you’re someone who eats a lot of sugar-laden foods, or generally is eating a high carb, low fat diet, you may be more prone to these blood sugar swings that can lead to hypoglycemia symptoms. In this case, a reduction in carbs and an increase in fat at meals will help keep your blood sugar levels steady, and get you off the blood sugar roller coaster. But if you’re already eating a very low carbohydrate diet, a bit of healthy carbs at each meal may actually help normalize your blood sugar too, so it’s important to consider your current dietary habits before dropping your carbs any lower.

And if you’re completely unsure where you stand on this issue, it might be worthwhile getting some help with your diet!

Neurological Disorders

One of the oldest uses of a ketogenic diet has been the treatment of seizure disorders  – even the Bible refers to fasting as a treatment for “fits”, and the ketogenic diet has been used by doctors as a treatment for epilepsy since the early 1900s.

Though the creation of anti-seizure medication significantly reduced the reliance on this treatment, there has been a surge in the demand for this therapeutic diet over the past 20 years. These days, there are even dietitians who specialize in the ketogenic diet who work with patients, mostly children, suffering from frequent seizures.

Other neurological conditions that have been shown to respond well to a ketogenic diet are Parkinson’s disease, Alzheimer’s disease, ALS, stroke, and dementia. (1, 2, 3, 4, 5, 6) In fact, Alzheimer’s disease is now being referred to as Type 3 Diabetes, highlighting the importance of blood sugar control in managing this often devastating condition. Ketogenic diets may also be therapeutic in the treatment of traumatic brain injury, a major cause of mortality and morbidity in young adults. (6a)

One of the most comprehensive books covering the role of a low carb and/or ketogenic diet in the treatment of neurological conditions is Grain Brain by Dr. David Perlmutter, a well known neurologist. Dr. Perlmutter has had a great deal of success using low carb, grain-free, and ketogenic diets in the treatment of thousands of patients with neurological disorders.

However, it’s important to remember that while these very low carb diets are helpful in treating these conditions, it’s unknown whether or not these restrictive diets would be necessary to prevent these conditions. Ultimately, I’d personally reserve the use of a ketogenic diet as a treatment for neurological disorders rather than a long term preventative diet.

Mood Disturbances

Similar to the neurological conditions already discussed, low carb and/or ketogenic diets may be helpful in reducing or eliminating symptoms of mood disorders like anxiety or depression. Some preliminary evidence suggests that these diets can have similar effects as antidepressant drugs. (7) Most of the research has been conducted in animals, but there have been studies showing benefits in improving aggression, fear behavior, and overall mood and quality of life. (8, 9, 10, 11)

On the contrary, one study demonstrated a decline in overall mood in subjects on a low carb diet, energy-restricted diet compared to a low fat diet, while another showed a decline in mood in female cyclists following a low carb compared to moderate and high carb diets. (12, 13) There hasn’t been a ton of research on this issue, so ultimately you’ll have to determine for yourself what the appropriate level of carb intake will be for your particular mood issues. I’ve seen plenty of clients (myself included) who find that their levels of anxiety skyrocket on an excessively low carb diet, so what works for one person (or a rat!) may not work for you.

Whether or not carbs are at play in your anxiety or depression, there’s a major role for a healthy diet and ancestrally appropriate lifestyle.

I do believe food is medicine when it comes to mood issues, and I’ve seen multiple clients get off their antidepressants after making targeted, individualized changes to their diets, even if they were already eating “Paleo”. And none of these improvements required strict carbohydrate restriction, so a moderate intake on a nutrient-dense diet may be enough to see positive changes.

Polycystic Ovarian Syndrome (PCOS)

PCOS is an incredibly common endocrine issue in young women, with a prevalence as high as 15%-20% of women. Typically, PCOS affects ovulation and menstrual function in women, and can also cause an androgen excess. These changes are the root cause of many of the most frustrating symptoms, including amenorrhea, acne, hirsutism (male-pattern body hair), weight gain, dandruff, thinning hair, and mood issues.

One of the primary dietary recommendations for women with PCOS is to limit refined carbohydrates and sugars, and to generally follow a lower carb diet. (14, 15) Reduced carbohydrate diets can help improve body composition, increase fat loss, repair insulin sensitivity, and promote menstrual regularity in these women (16, 17, 18)

One pilot study found that overweight women following a low-carbohydrate ketogenic diet lost weight, reduced their testosterone levels, and decreased their fasting insulin. (19) These women also experienced non-significant decreases in insulin, glucose, testosterone, HgbA1c, triglyceride, and perceived body hair. Two women even became pregnant during the study, when they had previously been experiencing infertility.

But before those of you with PCOS jump straight on a ketogenic diet, it’s crucial to note that there was no control group in this study. So it’s hard to know if the ketogenic diet was really necessary to get these results, or if a significant reduction in sugar, processed carbs, and grains might have been adequate, while still allowing these women to get a substantial amount of carbs from Paleo-friendly fruit and starchy vegetables.

You may find that the right diet for you allows for plenty of healthy variety, and that a reduced carbohydrate, whole foods diet is enough to get you on the right path towards healing from your PCOS.

Small Intestine Bacterial Overgrowth (SIBO) and Reflux (GERD)

SIBO and GERD seem to be increasingly common these days, likely stemming from our overuse of antibiotics, inadequate exposure to healthy bacteria, poor dietary choices, and high levels of stress. In my work with clients, I’ve also noticed an uncanny connection between SIBO or reflux and a history of binge eating or bulimia disorder, so I’d guess that overeating in general can put someone at higher risk for low stomach acid and an overgrowth of bacteria in their small intestine.

You can get great information about reflux from Chris’s free eBook on the topic. And if you’ve never heard of SIBO and you don’t know what the primary treatment for this condition is, I’d suggest listening to this podcast that Kelsey Marksteiner and I recorded for a great primer on the subject. But I’m sure some of you reading this either know what SIBO is, or actually have SIBO yourself. SIBO and reflux are often found simultaneously, so that’s why I’m lumping these two conditions together.

One of the primary dietary treatments for SIBO and reflux is the restriction of fermentable carbohydrates, often referred to as FODMAPs. But some practitioners even recommend using a completely low carbohdyrate or ketogenic diet, as some bacteria can feed off of low FODMAP carbs and starches. It may depend on the severity of your SIBO case, and some SIBO patients do just fine restricting FODMAPs and simple sugars. And if you’re eating too many high FODMAP veggies on a low-carb diet, you may actually make the problem worse!

Generally for reflux and/or SIBO, I tend to recommend a lower carbohydrate diet which restricts fermentable carbohydrates and sugar, but allows for a moderate amount of starches such as white rice or potatoes, which are often well tolerated. So while a strict low carb or ketogenic diet may be useful in dealing with these digestive disorders, I don’t think that it’s necessary to stay on these diets indefinitely to get the results you’re looking for.

Cancer…?

At the risk of opening a giant can of worms, I’ll briefly mention that there are many scientists, doctors and clinicians who promote the use of a low carb ketogenic diet for cancer. The major argument is that unlike the majority of our body cells, cancer cells lack the ability to metabolize ketones, and require a significant amount of glucose to survive and replicate. Since a ketogenic diet can keep blood sugar low, the theory (in a nutshell) is that cancer cells won’t be able to survive and thus the cancer will not grow and metastasize. Some doctors have reported amazing results in the use of these diets in helping their patients go into remission.

There are a few studies that show potential benefits for some (but not all) cancer patients, especially brain cancer. (20, 21, 22, 23, 24) But another study showed that in 16 patients with advanced metastatic cancer, only 5 of the 16 patients recruited could even stick to the diet, and none showed any remission of the cancer, so it likely depends on the type and severity of the cancer whether or not a ketogenic diet will make any difference to the outcome. (25) And none of these studies show any data that suggests a ketogenic diet would be necessary or helpful to prevent cancer.

When it comes to dietary recommendations and carbohydrate restriction for cancer patients, I don’t know if there’s enough data on the subject to make a strong recommendation either way. Ultimately, we’ll always have some level of sugar circulating in our bloodstream, and while I agree that good blood sugar control is likely helpful in preventing cancer in the first place, I’m not entirely convinced that a ketogenic diet is the best diet in all cancer patients, especially for those who are in more advanced stages. And having had relatives die from advanced stage cancer, I can also understand the fear that would come from feeding a cachexic cancer patient a hypocaloric ketogenic diet if they’re already wasting away.

For now, I’ll “plead the fifth” on this topic, and wait and see if more studies come out in the future supporting this particular therapeutic use of the ketogenic diet.

Important Considerations When Starting a Low Carb Diet

As you can see, a low carb diet can be a good choice for certain people, as long as they pay attention to several important factors that can ensure their nutritional status isn’t negatively impacted by this somewhat restrictive diet.

The biggest issue I see with many people who first switch to a low carb diet is that they’re unintentionally undereating, largely due to their discomfort with eating enough fat to make up for the carbs they’re not consuming. While this can be okay in the short term, especially for weight loss, over time this can lead to malnutrition and unhealthy stress on various organs, and may even cause weight gain as the body tries to conserve energy. If you’re on a low carb diet, make sure you’re eating enough to support your daily activity and to get a wide range of nutrients.

Also, even though some of your favorite foods might be low carb – like bacon, cheese, steak, and butter – make sure you’re still eating plenty of nonstarchy vegetables. These will help keep your gut bacteria healthy, as well as providing a variety of important minerals that can get deficient on a low carb diet. Potassium is a particular mineral that is prone to deficiency on a low carb diet, so eating a wide variety of vegetables and low carb plant foods at every meal (in addition to nutrient-dense animal foods) will help keep you nourished.

Avoid low carb products sold in the grocery store. These products often have artificial sweeteners and other additives that make them taste similar to their high carb counterparts, and sometimes can cause digestive distress in larger quantities. If you’re going to do a low carb diet, make sure you’re still eating real food and not buying a ton of low carb packaged food to replace the junk food you used to eat.

It’s important to keep an eye on your blood work as well, since not everyone experiences positive results on a low carb diet. Franziska Spritzler is a low carb dietitian who explained the adverse effects she experienced on a low carb ketogenic diet, with her LDL cholesterol and particle number shooting up to a potentially dangerous level. While this won’t happen to everyone, if it does happen to you it may be a sign that the diet isn’t a great choice for your long term health.

Finally, pay close attention to how you look, feel, and perform while on a low carb diet. While you’ll need to give it some time to truly determine if the diet can support your activity, energy, and daily lifestyle, it’s hard to know who will thrive and who will crash and burn on a long term low carb diet. If you’re experiencing negative health effects like excess weight gain, sluggishness, mood issues, or poor athletic performance after trying the diet for several weeks, it may be a sign that you’d do better on a more moderate carb approach. Don’t let someone else’s experience with the diet dictate how you should expect to feel. You’ll be your own judge when it comes to figuring out the most appropriate diet for you.

And if you need help figuring out how to optimize your carbohydrate intake, don’t hesitate to get in touch with me – I’ve worked with dozens of clients in this situation and can help you figure out if a low carb diet is right for you. You can sign up for a free 15 minute consult and we’ll discuss your nutrition and health concerns and determine if you’d benefit from professional and personalized guidance.

Now I’d like to hear from you – what side of the carbohydrate “fence” are you on? Low carb? Moderate carb? High carb? How did you figure out the right diet for you? Share your story in the comments below!

Laura Schoenfeld MPH RDAbout Laura: Laura uses her knowledge of traditional and biologically appropriate diets to improve her clients’ health. Growing up with a family that practices Weston A. Price principles of nutrition, she understands the foods and cooking practices that make up a nutrient dense diet.

With her strong educational background in biochemistry, clinical nutrition, and research translation, she blends current scientific evidence with traditional food practices to help her clients determine their ideal diet.

You can find her at AncestralizeMe.com, on Facebook, and Twitter!

111 Comments

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  1. Low carb Paleo has helped reduce my fibromyalgia and CMV symptoms greatly over the past three years, and I’ve found that after an initial adjustment in about the first year, my carb needs increased. I’d love to see some discussion of how we may go through long-term phases with adapting to a Paleo/low-carb diet (I suspect an “arc” of adaptation). It’s great to see attention paid to customizing this nutritional paradigm to individual needs, of course, and I also think that we have to look at how short term cycles (seasonal, stress, exercise intensity – even a rough week) and much longer ones (adaptation to Paleo or low-carb eating, hormonal changes, weight loss, increased/decreased muscle-mass) affect dietary prescriptions. Hopefully, for most people, the accurate signaling created through healthy eating plus a long lesson in self-awareness will make this a natural process.

  2. Thank you Laura for another awesome article! As a fellow practitioner, it’s always important to figure out the biochemical needs of the patient above all else, and I Iove how you and Chris embody this approach, especially when it comes to carbohydrates.

    From a personal standpoint, I was able to use a ketogenic diet to help overcome a genetic predisposition to my body’s inability to make enough methyl and corresponding copper overload which lead to massive depression, high anxiety, bulimia, and lack of menstruation.

    Menstrual disorders almost always have a copper overload component so it makes sense that a VLCD would create a pathway for healing since plant-based diets are very high copper diets. And copper/ zinc dysregulation impacts many pathways, especially those related to cognitive performance.

    Regarding low fluidity and mucus production, folks that make too much methyl tend to have this issue so it makes sense that they would struggle on a VLCD since folate is a powerful demethylating agent.

    Once again, thank you for a wonderful post and the amazing work you are doing in the world.

    You too Chris! 🙂

  3. After years of fiddling with my carbs, I still haven’t nailed it. I’m pretty sure VLC is not for me, but as I experiment with increasing carbs, I run into problems that probably have more to do with what the carb sources are stirring up in my gut. I get symptoms of inflammation (I can see it in my skin and my eyes pretty quickly). I’m experimenting with white rice now, as eating sweet potatoes regularly caused problems. I have a feeling that a lot of people think they do better on low carbs, because of gut issues. It’s definitely a confounding variable.

    • Sometimes carbs that are high in FODMAPS, like sweet potatoes, can be more of an issue than those that are low in FODMAPS, like white rice. This is especially true for people who have gut dysbiosis and/or SIBO.

  4. Thank you for readdressing this topic.

    I’m a bit surprised that you did not refer readers to perhaps the best and most practical book on the topic of keto-adaptation, The Art and Science of Low Carbohydrate Living, by Jeff Volek, PhD, RD and Stephen Phinney, MD, PhD. These gentlemen have been researching the topic for many years with both animal and human subjects and have the easiest-to-understand explanation of the hows and whys of a healthy low-carb diet. The book was written for health care professionals but the average person with an interest in nutrition can easily absorb the science. What the above article only skims, Volek & Phinney discuss in-depth.

    One of the fascinating things I learned from Volek & Phinney is that a low-carb lifestyle (not only as a temporary health or diet fix, but the long term) can be very effective for high-endurance athletes such as marathoners and ultra-marathoners. It eliminates the dreaded “bonk” or “wall” that carbohydrate-adapted runners experience and allows for faster recovery times. (For those who might be interested in specific recommendations for athletes, Volek and Phinney have written a companion book that addresses training on a low-carb regimen.)

    Generally speaking, the message is that many people thrive on a low-carb diet, provided they eat a lot of the right kinds of fat, a moderate amount of protein, and supplement with salt.

    Based on my reading of Volek and Phinney, I know that some of the advice given in the article above is problematic: “If you’re experiencing negative health effects like excess weight gain, sluggishness, mood issues, or poor athletic performance after trying the diet for several weeks, it may be a sign that you’d do better on a more moderate carb approach.” Volek and Phinney make the point repeatedly that it takes at least a couple of weeks for a person simply to become keto-adapted so that their bodies are efficiently burning fat instead of carbs. If you give this diet several weeks and don’t feel well, that’s to be expected. At that point you haven’t been on the diet long enough to know whether it will work for you. You must give the diet at least a couple of months, AND devise a diet plan where you’re eating the proper amounts and proportions of fat and protein, before you’ll be able to assess whether it has benefit for you. If you lose weight when keto-adapted and feel well, Volek & Phinney would recommend that you stay that way for the rest of your life. Can it be done safely and healthily? Yes.

    Many of our hunter-gatherer ancestors ate a ketogenic diet because that’s what was available to them, and they thrived for generations. We may not all want to eat that way today — personally, I can’t become totally keto-adapted for a variety of reasons — but it is a viable alternative that’s worth investigating.

    • What’s your evidence that many of our hunter/gatherer ancestors ate a ketogenic diet? In the case of the Inuit, that idea has been undergoing a lot of scrutiny (see the FreeTheAnimal blog).

  5. Why is there so much concern over LDL levels? I thought cholesterol was good for you (hormones, cell membranes, brain, nerves, etc.).

    • Because people prefer a terrible explanation to no explanation at all. So instead of looking elsewhere, people hedge their intellectual bets by regurgitating the same ol’ same ol’…

    • Because we still don’t know with any certainty that having elevated apo-B or LDL-p (particle number) does not increase the risk of artheroscelrosis, other things being equal. Until we know this I’d rather err on the side of caution. When my LDL typically sits in a range of 150-180mg/dL (which I’m totally comfortable with given that HDL is in the 80s and Trigs are in the 60s) but then I go very low carb and LDL shoots up to 230mg/dL while my mood and performance also decreases this begs the questions – is a VLC diet optimal for me? Probably not.

      • 230mg/dL of LDL, in & of itself says…what exactly? Not much. All-cause mortality curve (dudes) favors you. https://www.dropbox.com/s/hp4i60l5fvp4xjy/All-cause%20mortality%20v%20TCholesterol.jpg?dl=0 For women (due to hormonal differences) a higher TC level is probably preferable to a low one – all other things being equal – & especially the older you are!

        ApoB helps transport lipids. You eat more lipids. That’s just adaptation. The problem is the interplay between everything else that has ZERO to do with how much fat you eat (except the kind of fat). Your sleep, your detox abilities, your circadian timing, micronutrient deficients, mitochondrial integrity, immune reactions.

        You have to distinguish between studies making correlations & being able to quantify it within a causal framework.

      • Since atherosclerosis is a gradient-driven process, assuming all other things are equal (diet, lifestyle, inflammation, etc.) if one person has high LDL-P and the other has normal LDL-P, the research we currently have suggests the person with high LDL-P will be at higher risk for CVD.

        As we learn more about genetics and epigenetics, we’re finding that different people react to foods in different ways. A VLC diet may be optimal for some, but may very well increase CVD risk for others. Studies may not pick up on this well because they deal with averages. If some people’s risk goes down, while an equal number of people’s risk goes up, the net affect is nil—but that obviously doesn’t help you if you’re one of the people whose risk went up.

        • I don’t disagree with that data. The data is currently limited, though:

          – it’s highly correlative
          – it lacks mechanism
          – combinations of multiple markers overshadow its predictive utility
          – it hasn’t been studied in HF dieters to any significance AFAIK
          – endothelial function & physiological (exercise) assessments are, in totality, quite superior to apoB.

          So while it certainly is interesting & wouldn’t put so much certainty in needing to lower it if that means going against better understood principles & other valid markers contradicting it.

        • Thanks for jumping in and clarifying, Chris. I welcome the backlash against the outdated ‘cholesterol is bad’ camp but I think some people go too far in the opposite extreme that ‘the higher your cholesterol the better!’ Given that a VLC diet consistently spikes my already high LDL-P, I can only assume that this type of diet is not optimal for m.e

          • It just so happens that the higher your cholesterol in old age, the better off you are in healing, resisting injury, and other things–same goes for BP. A systolic of 150 or more is actually BENEFICIAL at that age, because it assists in circulation when the rest of the body has slowed to a crawl.

            • Wenchpoo, I am in my mid- 70’s, BP 115/65 eat right, workout, run, and nothing has ‘slowed down to a crawl.
              Don’t generalize, people are individuals, which is the point of this article?

      • It might not be the “Low Carb” or “Ultra Low Carb” diet that is spiking your LDL particle # but what your consuming when going low carb.

        Look into Dr Gundry’s work on why this occurs in some people. Look for an interview from John Keifer for Dr Gundry. (A2 dairy vs A1)

        Also find out what your APOE status is. Mine is E3/E4 and I have to be careful with too match saturated fat from Animals according to my Dr. (Rakesh Patel) but I a sneaking suspicion that its the high amounts of Omega 6’s found in conventional beef and cheese that are not grass fed sources that attribute to this. In one of Chris’s podcasts way back when he mentioned something about Oxidized Linoleic Acid being assoicated with dense LDL particles that I could see being found when consuming convention animal products.

    • I have read in several places that its not total LDL that is a risk factor for atherosclerosis, it’s only small LDL particles: a subclass of LDL. These small particles penetrate into arterial walls where they are oxidized (thus “oxidized LDL”) and consumed by macrophages. A macrophage full of oxidized small LDL eventually leaks or bursts, resulting in inflammation.
      The body covers the inflammation with “plague” and the ensuing viscous cycle hardens and may block the artery or cause an embolism.
      Your understanding that cholesterol is needed is correct. Larger LDLs are important as they deliver cholesterol and some triglycerides to cells that need them or to the liver.
      They are what’s left of VLDLs after much of the triglyceride load they carry from the liver has been been unloaded to cells for storage and other uses.

    • Not LDL. If your ratios are fine,than no worry about cholesterol. But LDL is a different animal. Also, do PLAC test,if you worry. No need for a prescription through PrivateLabmd.

      • Ive seen incredibly good PLAC values in prople that have heart disease. You CANNOT use one indicator to determine your CVD risk. EVERY marker needs to be looked at!

  6. Superb article, Laura. I’m so glad Chris found you and I look forward to more well-thought, balanced articles like this. I thought I’d contribute my two cents on the topic of very low carb diets:

    As a relatively fit, healthy dude practicing Paleo for almost five years I didn’t have any of the above conditions that may warrant trying a (very) low carb diet. But when I continued to read respectable and influential authors like Gedgaudas, Perlmutter and Taubes promoting an extremely low carb diet and vilifying carbs I consciously cut carbs even lower than they already were, probably to 30-70g a day at 190lb lean bodyweight. After a couple of years of mixed and often negative results on a low-carb diet I started to shift my opinion. Thanks to (more reasonably approached) people like Chris, Robb Wolf, Paul Jaminet and Mark Sisson I’ve really come around on my thinking about carbs. Here’s what I found:

    1. Very low carb diets are not a short-cut to staying lean. As Gary Taubes or Jimmy Moore will attribute, all that cream and bacon can and will make you fat if you over consume it, even if you are eating <30g carbs a day. VLC is not a free pass to being a glutton.

    2. Very low carb diets and high intensity exercise do not mix well. I almost broke myself trying to stay VLC while also doing CrossFit. Gluconeogenesis simply doesn't cut it when you're smashing yourself daily at the gym in glycolytic pathways.

    3. My LDL and apo-B really shot up on a VLC diet. Once I added carbs back LDL and TC dropped about 25% while HDL and trigs remained good. i.e. My blood work worsened on VLC.

    4. The vilification of carbs is unwarranted. 'Carbs' are being treated now like 'fat' was in the 80s. Just as fat won't make you fat, carbs won't make you fat… give that you eat high quality (Paleo) carbs in reasonable quantities. No need to fear carbs, people!

    5. I don't think macronutrient breakdown makes any difference to body composition when carbs are in the 10-40% of calories range but I certainly feel much better (especially mood, energy and sleep) at the 20-30% range.

    In summary, if you are relatively lean, healthy and active and therefore don't necessarily NEED to go very low carb then please proceed with caution. (Very) low carb diets are not optimal for everyone, I assure you.

    Thanks again for a great read!

  7. Excuse me, I don’t see in this article a reference about the hormonal impact noticeable in the first months on Low Carb diet supported with Energy from fats…,and then the eagerness for stay active, this is my experience and the reason why calories in- calories out thorie comes to an end in real life.

  8. Any suggestions on how to find the right amount of macronutrient intake based on my activity level, goals, etc? Thanks!

  9. Another great article Laura! I loved your first article and “staunchly” agreed with you. Being active and now healthy I do much better with an increase in the right types of starchy carbohydrates–about 30+ ish%. Varies with training vs rest days.

    Where am I on the fence? Low carb for all the reasons/conditions you stated in this article (and the last:). Mod – higher carb depending on activity levels/genetics/health/how you feel/how you perform. You have to experiment.

    You spelled it out perfectly in the 2 articles. It’s not rocket science and there’s no one size fits all. I think way too many people are looking for a quick fix or that magic bullet. Takes effort and experimenting.

  10. I have followed paleo-immune diet for about 4 months to deal with eczema. It took away my food cravings, cleared up most of the eczema and I got quite thin. However, I developed very dry crusty eyes in the morning, had difficulty sleeping for more than a few hours and felt like I was drying up. I wasn’t aware that my carbs were low because I ate a lot of vegetables but they were all low starch and low carb. I added in more carbs and starches and feel better. I am afraid of gaining weight but don’t have a choice.

  11. I’m apoe3/4 so I don’t think low carb would be good for my lipid profile.

    I have about 10-15 lbs to lose and am trying to do it via Carb 50% (avoiding potatoes and whites) Fat 30% (Mostly Mufa) and Protein 20% (Mostly plant based but some chicken/fish).

    After my next lipid profile (late November), I’ll be in a better position to comment.

    From what I read, those who are apoe 2 would respond well to a low carb diet, so I guess our genetics do determine our optimal diet.

    To each their own.

  12. I have been on a low carb diet (autoimmune paleo) for about a year now and my LDL has shot up, as you mentioned – Why is this and what do I do about it?

  13. Hans Selye’s framework of adrenal stress is often used to explain LC-induced adrenal fatigue. Problem is, it is quite outdated (although historically valuable).

    A broader & more modern consideration of the HPA axis feedback system doesn’t support the idea that low levels of dietary carbohydrate per se cause or trigger adrenal stress responses.

    There is much more to be explained by looking at hypothalamic inflammation (toxins) via mismatched circadian shifts (sleep) or even ‘simple’ “hyperglycaemia driving reverse electron flow from mtG3Pdh through complex I to generate insulin resistance” [Petro @ Hyperlipid]. & so on & so on..

    Have you considered reassessing the validity of Hans Selye’s framework as regards the supposed LC-adrenal stress connection?

    Thanks

  14. How much impact does a low carb diet have on gut flora? Wouldn’t it be best for people on low carb diets to take prebiotics if they tolerate them?

  15. I follow a LC diet since 2007, I started it to control migraines which were looking like an epilepsy on EEG. It worked, but at the same time my allergies improved and I stopped having all sort of infections. I lost only 30 lbs. I would gain weight now (but not at the beginning of my diet) even limiting carbohydrates if I were eating as much as before, but my appetite is low now.
    I would add to your list of the people who could appreciate LCarbing more than others the people who have frequent infections.

  16. I have LADA and switched to low carb within weeks of diagnosis. I lost over 20% of my body weight within 8 months. That was almosr 6 years ago, and the weight is still gone. My blood sugars went sky high last winter/spring despite training for a triathlon, so I went on insulin this summer. The readings are better, by still not where I want them. I have also found that keeping a food diary with an app like MyFitnessPal keeps you on track with your carb/fat/protein intake, and you are less tempted to over snack if you are recording everything.

  17. This has probably been asked in other sections of this website before, but what do you do in situations where SIBO coincides with Hashimoto’s-induced hypothyroidism? I’ve read Chris’s e-book on bother GERD/IBS and Thyroid Conditions and have seen advice about the use of low FODMAPS/LC diet as a potential therapy for SIBO, yet these books also say that it isn’t recommended for by with hypothyroidism. What approaches should I look at if SIBO is an issue (I live in NZ and the comprehensive stool analysis tests are very expensive here as they must be sent abroad to be analysed…)

  18. if someone is obese, wouldn’t it generally make sense to go on a LCHF diet unit a desired weight is reached, then move to a more paleo style diet to maintain that weight level? Once they have reached their desired weight their activity levels will most likely have increased thereby offsetting the increase in calories.

  19. I agree 100% that I feel great when I adopt a Low-carb diet. However, I have a lot of trouble sleeping when I do. Eating low carb causes me to wake up four or five hours after going to bed, unable to go back to sleep. Am I not eating enough protein or fat? Am I not getting enough calories? If anyone has any insight, Laura or Chris, please share. I really want to improve my health, but I just can’t seem to sleep enough. Thanks for reading, hopefully someone responds.

    • I’m not an expert like Laura or Chris and this probably goes against the mainstream advice on this site, but I used to suffer from the same problem when I was low carbing. I now consume most of my carbs either post-workout or pre-bed – I find they help you relax and are more conducive to sleep. My theory is that when you’re low carb and possibly in a calorie deficit, secretion of catecholamines is increased (along with other hormones to optimise usage of fat for fuel) and the main way of off-setting this is by consuming carbs. Carbs will also help you make more serotonin (involved in relaxation) from which melatonin (the sleep hormone) is derived. This is just my personal experience and theory though.

    • If your blood sugar is dropping low overnight, your body will release stress hormones to help bring it back up, thus waking you up. Try eating some whole food carbs with dinner or before bed and see if that affects your sleep!

            • Alexander

              I do not think that the –first– approach for someone who is not normoglycemic is to throw in more of that which they cannot handle normally (carbs). Also, your body has a system to always maintain an adequate level of carbohydrate for your brain, red blood cells etc.. ==> gluco(sugar)neo(new)genesis(creation) [creation of sugar = gluconeogenesis]

              It is tempting to see all paths forwards with a simple “upping” or “downing” of macronutrients. If only it were so simple…

              1 way forward would be to ask yourself how to best support your bodies systems that:

              1) produces sugar when needed (as mentioned above)
              2) ensure that once the sugar is circulating, it goes where it needs to (insulin, glucagon etc.).

              One way forward is for you to focus on getting in the highest amount of micro-nutrition per calorie consumed. To achieve that, I would suggest you focus on eating lots of seafood (crustaceans & fish) & offal (liver & animal odd bits). It’s also cheaper usually then conventional meats. Don’t try to purposely fill yourself up with fiber – this will only make you ‘feel’ full temporarily without actually providing useable energy to your actual cells (which is what we’re all made of!) [*exceptions not withstanding; e.g. colonocyte feeding on SFAs]

              Last tip: buy a $5 pair of blue-blocking glasses & try to be in sync with natural light cycles. This is insanely effective. If you can’t sleep & you’re in one of the lucky states, try to use edible or vaporised marijuana that is CBD predominant. Or, try CBD oil in its various applications.

              Ultimately, yes – you can have problems on LC diets. They’re no miracle. But try not to fall into the trap of thinking that because 2 things happen at once that they must be causally related.

              Good luck!

  20. “The longer a person stays on a low carb diet, the more they may start to find ways to make their diet more palatable, and thus increase their overall calorie intake.”

    This is true. But it’s true of any diet. The underlying prejudice is that a LC diet isn’t palatable. I personally find meat, LC vegetables, and limited berries, plus whole-fat kefir/yogurt with various flavorings much more paletable than a low-fat diet.

    • Yes, this is the problem with many diets. Adherence tends to drop over time because people have trouble sticking with a diet that is less rewarding and palatable.

      • I think it’s not so much palatability as lack of variety and difficulty in social situations in which the majority don’t follow your way of eating.

    • You described my eating style exactly. I’ve been eating this way for several years, and am very happy with the results. Blood sugar stable, lipids normal, and feel great.
      And I never have had a problem sticking to it. Just feels natural.

    • There are many people who try to replicate some of the junk food they miss on a low carb diet – and there are hundreds of blogs dedicated to low carb dessert recipes. Eating whole foods versus recreating low carb versions of calorie-dense treats is completely different, and unfortunately I see a lot of people going down the road of the excessive low carb junk foods.

      • Reddit’s section called r/ketorecipes doesn’t help, either–they tend to shoot for 5 net carbs/serving, and they don’t care what shortcuts they have to use to get there: flavored syrups, off-the-shelf LC breads and tortillas, artificial sweeteners, etc.

        Pizza, dessert, and replicant junk food recipes are the faves there. I tried to inject some REAL FOOD recipes in there, but got drowned out because I refused to bow to the artificial ingredients that reign supreme there. I left after about a month.

        People complained that the recipes I posted links to took “too much time to make” and were “too complicated.” I think they were just addicted to their shortcut products.

        You know the old saying about leading a horse to water…

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