It's quite a learning curve for some people because I'm telling them, listen, you got to eat fat. They've been avoiding fat all their lives. You got to put salt on your food. They've been avoiding salt all their lives, even though they don't know that they've been getting a ton in processed foods. So, it is it is a huge learning curve. Are you considering starting a ketogenic diet or ketogenic therapy, but concerned about what you see online or hear from others about nutrient deficiencies, about the risk of gout or bone density problems or acidosis or even
eating disorders and social isolation and and on and on and on. There there can be a laundry list of things you can read about concerns with ketogenic diets. Well, I'm joined by Beth Zubet Kenya, who has over 30 years of using ketogenic diets as therapeutic interventions. And she gives us her perspective on this whole laundry list of the ones I mentioned and more about how maybe some you do need to be concerned about and steps you can take to address them and how some are kind of misconceptions. So, here's the interview with Beth Zupca. Well,
Beth Zupca, welcome back to Metabolic Mind. Thanks so much for joining me again. Well, thank you for having me. And I'm excited to really get into a lot of the details about the the maybe concerns with ketogenic diets, what's real, what's maybe a misconception, what are some of the the nuances. Um, and you are sort of the perfect person, I think, to to talk to about that. So, but before we get into the details, please just tell the audience in case they don't know who you are, just who are you and why why' I pick
you to talk to you today. Yeah. So, I'm a registered dietitian nutritionist and I've been working with ketogenic therapies for over 30 years. uh about 20 years with pediatric epilepsy and then the past 10 plus years with many different disorders including uh cancer and other uh neurological disorders, migraine, headache, um mental health uh has been a big change in the past three or four years um that I've been working with and and then metabolic genetic disorders is kind of my specialty because I did a lot of that with pediatrics. And um that's a whole interesting
field because people are born with a genetic metabolic effect and the diet can make a huge difference in their health. Um the hard part is that they're on it for their entire life at at some degree. So I followed people since they were babies and now they're adults. Uh so that's that's a bit of my background. Yeah. I mean, and and like I said, that's why I think you're you're just the perfect person to talk to about this. There aren't many people who can say they've been involved with ketogenic therapies for 30 years, but also
spanning the lifespan from the babies to the adolescence to the adults. And I think that part that perspective is so important because I think a lot of the concerns about ketogenic diets maybe come from the pediatric population. And one of the questions we have to say is does that translate to adult populations and different formulations of the diet. So we'll get into all those details, but I think that might be a theme. Um so let's jump in right away to to the first um concern that I see all over the internet in different articles on
Harvard Health and even one in like Chicago Medical School about ketogenic diets are going to lead to nutrient deficiencies. vitamin B, thyon, folate, um, calcium, iron, magnesium, vitamin D, right? You see this laundry list of nutrient deficiencies with a ketogenic diet. Is that a concern? Yes. So, I'm glad you brought up uh the research in pediatrics, uh, because that that is probably where a lot of that stems from. But first, I'm going to back up and say, um, deficiencies versus insufficiencies of, you know, of someone's diet. We don't really know really if people have deficiencies
unless we go on a hunting trip to do blood work and that's generally not done. But the claims are that the diet is widely deficient in many nutrients. And I know that comes from pediatrics because this is where we have used the classic ketogenic diet. The 4:1 ratio is what I used for several years before I realized that we didn't have to be that strict. You know what a four to ratio one ratio means is a 90% of the calories in the diet comes from fat and that means 10% allocated to protein and carbohydrates. So
we're talking about less than five grams a day of carbohydrate. Well, how do you possibly meet B vitamins and other vitamins in less than five grams a day? It's it is it's impossible. So I know this is where that's stemming from. We've evolved from those days of using the classic ketogenic diet even in children to much more liberal diets that are lower in fat, higher in carbohydrate and protein. And they still need to be supplemented because um not just due to concerns of the limited source um and maybe variety of food, but also just the
food supply. That's that's another concern here is our food is probably not as healthy as it once was. Um so it makes sense to supplement uh nutrients that are likely deficient and a good nutritionist can kind of figure that out just by looking at what people are eating. And um you know a multivitamin with minerals and trace minerals is a common um choice for supplementing somebody on a ketogenic metabolic therapy. Yeah. And it seems like you know when it comes to B vitamins, you know, the the cereals are all fortified with B vitamins. So for
a high carb diet, especially sort of a processed food diet, you sort of need those grains and cereals that are fortified with B vitamins. But where else can you get those? Um, if you're not going to eat fortified grains, one of the best places is green leafy vegetables. That's about the most nutrientdense and low carbohydrate food that you can include on a ketogenic diet. And um, it's very rich in fiber. There's some omega-3s. So, I encourage everyone to have a raw salad every day of some leafy greens. And it doesn't have to be spinach. It
can be a mixture of arugula, spinach, uh you know, baby lettuce leaves. So that it's interesting, but um you know that that is a great way to get B vitamins and vitamin A and even vitamin E and even some omega-3. So, um, nutrition still counts. Food quality still counts and and the term well- formulated ketogenic diet is referring to this selection of foods to optimize nutrients and fiber and feed your gut microbiome, these great nutrients that that real food has. Yeah. And that and that's why I think it's so interesting that that someone would say,
"Oh, well, if you're not eating these fortified grains, then you're not getting your B vitamins without realizing there are so many other places you can get them." And same thing, so you know, calcium and vitamin D, well, you know, if someone's, you know, eating dairy or, you know, then they're getting that. So, it just boggles my mind that somebody would say a ketogenic diet is by default deficient in calcium and vitamin D and then, of course, iron if you're eating meat. Like where do these things come from? Does it all like I guess you started
by saying it came from that 4:1 ketogenic diet. So do those have any relevance at all to sort of the modern-day ketogenic diet that most people are eating? No. Okay. us that are on these classic diets. And we did we do supplement children still on a ketogenic therapy who are are let's say on a more liberal ketogenic therapy because even though they may be getting dairy, they're probably getting heavy cream which is not the richest source of calcium. And even if they're eating a little bit of cheese, they can't have a lot of cheese because
there's carb and cheese because it comes from milk. You know, we still supplement children. But um calcium is one of those minerals that we don't tend to supplement adults with because their bones are done calcifying and giving them calcium might not be a good idea. And there's actually research that shows that supplemental calcium in adults could be negatively impacting their health. All right. Yeah. So I think that's really helpful um about the nutrient deficiencies and really that does seem to be um a misunderstanding um just about the ketogenic diet in general. So, I'm glad you
mentioned the microbiome because there is this uh perception that that you need to be eating a high carb, high-fiber diet to have a healthy microbiome. And yet, we see people, you know, making tremendous health gains by having low carb and low- fiber diets. Not that low carb has to be low fiber, but we see people on low- fiber diets having incredible health gains. So, how do you fit that into the microbiome changes and the concerns that you have to have high fiber for a healthy microbiome? Yeah. So, here's another one of those myths. Um, high-fiber
diets have not really been well researched. It's more based on guessing and, you know, looking at the mix of a high carb diet. I have plenty of people getting less than 10 grams of fiber a day who have daily bowel movements and the recommended fiber intake is 30 grams of fiber a day. So, you know, that that's a huge disparit, uh, amount, but um, what what I have come to learn is that there's a lot more than fiber that affects your microbiome. And one of these is prebiotics. This is kind of a new area of
research. And there's non-fiber prebiotics. And, um, olive oil is a rich source, extravirgin olive oil in particular, of polyphenols. And the one in particular in olive oil is called alopurin. And this um feeds gut microbiome and and makes healthy gut. And you can get a lot of olive oil on a ketogenic diet. Um and there's other sources of polyphenols. The the dark green leafy vegetables, um other vegetables, even sesame oil has some polyphenol in it. So what science is now turning to is that it's not just fiber. It's these non-fiber polyphenol sources of nutrients that
microbiota like to consume and that makes healthy, you know, bowel movements. And one thing I learned recently, hopefully this isn't getting too graphic, but twothirds of the weight of your stool is actually bacteria, not food stuff. Yeah, twothirds. That's huge. Um, so we want people to have have help uh, excuse me, we want people to have healthy digestion, daily bowel movements, and I've been able to work with people to achieve this just by adjusting their intake to better choices, the green leafy vegetables, um, maybe drinking more fluids, um, getting magnesium in in one of their
multivitamins or even a separate supplement. uh using herbal remedies um such as um senate. So there's quite a few options and we don't have to use laxatives. I think people should not depend on laxatives because they really aren't good for your your gut microbiota at all and people tend to get dependent on them. So in fact I take people off of laxatives. There's one laxative in particular that seems to be quite popular and that's um Mirillax and it used to be a prescription many many years ago and then it went over the counter and I
see it in in many uh intake forms that I review before I start working with people and I always um approach people with listen I have a lot of experience getting people off of this and getting them on to healthier plant options um you know what do you think about this And by and large, most people find it's it's pretty effective to to get off of a laxative and to rely on food sources or herbal remedies to help manage their digestion. Yeah. And and so you mentioned, you know, having a bowel movement once a day,
but one thing I always like to point out is that just because you're not having a bowel movement every day doesn't by default make it constipation. that there's a difference between having a perfectly normal bowel movement every two or three days versus being bloated and having pain and discomfort and and that's sort of the borderline of of constipation. Do you find that that comes up a lot that people come saying, "I'm constipated. This is terrible." But they're really just having a normal bowel movement every couple days. Yes. In fact, I have on my intake form
a whole section on bowel movements because I want to know, you know, how frequently and the the um whether they have loose stools, diarrhea, constipation, how frequently, and then the color of their stools. I've learned to ask because um we want to make sure people have a healthy source of bile in their gallbladder before we start pushing fats. And I've come across this several times um where I've been able to uh find out in advance before going on keto that people are already reporting that their their stools are pretty pale in color. And I'll say
that that's not normal. You know, you might not be making enough bile. Please get this checked out with a gastroentererologist before we start going towards keto because you're going to get into trouble or you may get into trouble if we start pushing fat. Um, and if and if they're really anxious to get going, I might just say, "Let's just start with some MCT oil, which does not use bile acids, but is a good way to get them going on a little bit, you know, of fat in their diet. Um, and and that makes them happy
to have something to work on that's moving towards keto, right? So, you mentioned bile acids. So, let's talk about the gallbladder. So people who have had their gallbladder removed, there's this perception that they can't have high amounts of fat. Um, and whereas I've seen, you know, people without their gallbladder tolerate keto perfectly well, just maybe have to go a little bit slower in the transition. So I'm curious what your experience is with that as well. I have found the same. So it it always is a red flag to me when I see that uh there's
a diagnosis of a gallbladder removal. Um but then I asked the same question, you know, what color are your stools? And when your gallbladder is removed, you actually um have a little sack that your body brilliantly creates as the new little pocket for bile acid. So you compensate and and you um have this ability to still make bile, still store it away and use it. And I think stool color is absolutely the question that has to be asked because that really tells you if they are making or not making bile. Um I had somebody recently
told me that sometimes their stools are completely white and like whoa. All right. You know, you really need to get into a gastroenterenterologist soon because that's not normal. That is really not normal. Um, and you know, and they're following basically a low-fat fat-free diet with occasional, you know, consumption of a little bit of butter here and there. So, it it's it's important to sort that out before somebody starts, but absolutely, people that have had their gallbladder removed can do keto. Yeah. Good. That's great. Okay. Um, well, let's let's get away from the gut for a
little bit here. And so, next, let's talk about sleep disturbances. A lot of people will report when they start um with a ketogenic diet that they have trouble sleeping. So, how do you approach that? Yeah, I have seen this. I've heard this report. Um I just was with 10 people who I helped uh in initiate a ketogenic diet. I was with them for two weeks and I ate with them every day and so I heard all the complaints of keto flu. Um, which you know only about half of them had but um uh there was
two people in particular that had sleep issues and one of them it was hunger. He was waking up hungry and he knew you know he's like I'm just hungry. I'm like okay we could fix that. You just need to eat more. And this was an unrestricted ketogenic diet. was not calorie controlling at all. Um but he was trying to be so cautious that he was not you know indulging himself and also um he was experiencing ketosis early so his appetite was not robust like it had been. This is a guy that was always hungry. He
had about 60 pounds to lose um and he was losing weight fast. In fact, a little bit too fast. I had to talk to him about not you know slowing that down. But um so his was hunger and I saw that a lot working in pediatrics that kids would wake up hungry. And so that was the sort of the impetus behind um fat bombs like let these kids eat more when they're hungry. We don't need to overrestrict. And in the old days of keto it was calorier restricted you know and this is this is why
kids did not grow well. They were on calorierestricted ketogenic diets for two or three years and you took them off and they their height, you know, popped up and um and they grew to their optimal height. This is exactly what happened to Charlie Abrams. He's over six feet tall and he was on the diet for five years. So he he was a a good example of that. But so I saw that in kids and I've seen it sometimes in adults. So I think that's one reason. I think another reason is more hormone related and maybe
thyroid hormone related, but it seems to be transient. It's in most people that I've worked with, like after a couple weeks that settles down and then they start reporting they sleep better. So, I think that's part of the transition into keto. Um, and if it's not, then I think that's when we need to start, you know, advocating to look at thyroid hormone levels and see if that's maybe involved. Yeah, I think that's a good point to to look for other causes um some hormone related causes. And then the other thing that I've I've seen and
used is having people sort of backload their carbs. So if you're going to have 30 grams of carbs during the day, maybe have, you know, half of that later in the day um rather than spread out throughout the whole day or even add a few more carbs at the end of the day and that can help with with sleep. I I I don't know the exact mechanism. Maybe it has to do with stress hormones. I don't know, but but I've seen that work. Do you have experience with that as well? Yeah, I I think that's
where um snacks these fat bombs and snacks come in and and and fat bombs are not all fat. They're actually a mixture of a little bit of carb, protein, and mostly fat. But I have found that if people if you give them permission to have a snack in the evening, um you know, that that kind of is comforting. They're used to many people are used to having something before bedtime anyways, but that seems to help um whether it's psychological or not or hormonal, I don't know, but it seems to help. Okay. And now, what about
a a keto rash? That's another one that some people report. Sort of this sort of diffuse rash generally over their chest, although it can present in different ways. Um that can be pretty itchy and can be troubling for people getting into ketosis. What's your experience with that? Yeah, I've looked into this because I've had a few people um apparently occurs more in women and it's tends to be located in the trunk area and it also in younger people versus older or elderly people. So that's been true in the situations that I have seen. Um there
is a uh Dr. Berg, who I found, um, looked into this and I I don't recall, I think he's a dermatologist, but he related it to a B vitamin deficiency and potentially vitamin A and vitamin D, which I think kind of makes sense. Um, that it could be related to that. So, I encourage people to start their supplements, you know, soon after we get going or even before we get going on the diet. And I like to look those over to make sure they're not getting a chunk of carb in them. and um you know
that it's a quality supplement. But um it could be that I've also had somebody who had it was actually a dairy allergy. They were not used to consuming dairy other than butter and then now they're putting cream in their coffee and eating cheese and their body wasn't used to it. So they had this little, you know, reaction that um subsided over time. And then I had one person where they were blaming the diet. We found out it was a change in laundry detergent. So yeah, right. You always have to have your detective hat on. You
can't just make assumptions. So that's good to know. Okay. Um, another concern that that comes up, and I think maybe more so recently because of some recent um, publications about it is the risk for bone density. And the way I see this is, you know, there was a study showing um increased markers of bone turnover, but I don't believe there's ever been a study showing actual decreased bone density or increased risk of fractures. And frequently I see the opposite. So, how do you approach people who are concerned about their bone density starting a ketogenic diet?
Yeah. If I hear that concern, I encourage people to go get um a DEXA scan done because you know really this the best way to do one at baseline. Um but I can tell you from pediatrics we did DEXA scans if anybody was on the diet more than three years. Most most kids were off in three years but plenty were because of these genetic metabolic disorders or they they kept having seizures when we tried to take them off. we would do an a DEXA scan and they were fine. They were fine. So I want to
believe that you know that that uh bone uh mineralization occurs in childhood mostly by the time you're 30 you're done building bone. You could definitely lose it but you're done building it. Um so I I want to believe that you know the mechanism is is not tipped towards bone loss although there is an exception to that. If anybody is taking um anti-seizure medications, which many are used in mental health and migraine headache, those interfere with um with your your bone mineralization. They can cause osteoporosis on their own, right? Those are the people that I worry
about. And so those are the ones that you got to make sure they're getting a good source of vitamin D, vitamin K, not necessarily a calcium supplementation, but they they do need to be followed. Make sure they're not in a state of acidosis. And that's when uh a state of acidosis would encourage loss of calcium out of their bone. Um that's that's where I've seen osteoporosis in in a lot of children that have been on anti-seizure medications for years. Well, but that has to do with the medication though, not the diet. You just have to
make sure that they're getting what they need because of the medication. Yeah, that makes sense. Yeah. Now, you mentioned acidosis. So, there is a concern that ketogenic diet is an acidic diet and you're going to put people in a state of acidosis which could leech the calcium out of the bones. Um, what is your your feeling about that? Yeah. So, I I don't think the ketogenic diet is an acidic diet. I think if you're on a ketogenic diet and you're on a medication that causes acidosis such as top pyramate zenithmide um maybe that gets exacerbated
and because I've seen that I think those people need to be watched carefully. They need to be on a buffer or evaluate to see if they can deprescribe the medication if they're getting good results from from keto. So that's where I see the problem. I've only seen um acidosis besides that situation in in people who are are undernourished who are not taking in enough calories. Right? So this is a state of malnutrition. The body is starting to break down its own lean mass and that puts them in a state of acidosis. I've seen that a
couple of times with really very impaired people who are not able to eat enough to keep their energy levels, you know, intact. Yeah, that's that's important to recognize. And then, of course, the concern with ketoacidosis, which a lot of people just associate ketosis with, not understanding they're completely different things. But when you're in ketoacidosis, as the name implies, you're in a state of acidosis. But for 99.9% of the people in ketosis, um it's different and you're not going to pick up acidosis in in the blood unless there is sort of a mitigating factor like you're
saying with the medication. So that's really important. Yeah. I just I'll add to that that when I was working in pediatrics and we would start up a child who was admitted urgently and put into the intensive care unit with non-stop seizures. So what they would do is put these children into a pentabarb coma to put them asleep, right? And if they couldn't get those seizures under control in a few days, we would often start keto through a feeding tube, right? So these are usually people that have been fasted for days. They're just getting IV nutrition.
So now they're fasted and I'm starting keto very gradually. I would see acidosis in these kids until they got them up to their full calories and then that would self-correct. So I know it can occur in a fasted state. Again, that's sort of related to malnutrition. In a very fasted state, you might see this acidosis, but it's not relative to being on a diet regularly and and you know, eating your full diet, right? And another great point, if you just Google, you know, can the keto diet cause acidosis, you know, you may get a hit
that says yes because of that exact circumstance you just talked about, which is completely different than people eating an adlib ketogenic diet. Um, so very good point to make there. Um, so another common one that that people can can experience are leg cramps, especially evening leg cramps after transitioning into ketosis. So how do you approach that? Yes. So I know um that going low carb or keto uh causes uh your eldoststerone your kidney hormone to excrete less and that causes this naturesis in other words a diuretic effect. So you your body lets go of fluid
and with that goes sodium and maybe and chloride right and if you don't correct that potassium is going to follow because your cells are going to start breaking down and potassium is intracellular. So now you're losing sodium chloride and now you're losing some potassium and magnesium. So the first the first cure of this is to make sure you're taking in a good amount of salt. You need to salt your foods on keto. And if you're not salting your foods, you need to take an electrolyte supplement, right? And almost everybody that I've talked to prefers just
to salt their foods. I say, you know, get your special salt shaker on the table by where you sit so you don't forget to salt every meal. Um, sometimes it's a teaspoon a day. It seems like a large amount, but um, a teaspoon is really what the recommended amount of sodium is for an adult. It's just that on a mixed high carbohydrate diet, you're getting a lot more sodium in processed foods especially. So, if you're getting away from processed foods because they high in carb and you're eating more whole foods which are naturally low in
sodium, we need to add salt to our foods to bring that back up because you're losing it for the reasons I just mentioned. So, sodium definitely and so with with salt you're getting sodium chloride and potassium for some people. Um, and there's a a salt called light salt, which is potassium, sodium, and chloride. You get all three minerals in one salt. And I have some people using that because the sodium chloride wasn't enough. The salt wasn't enough. Their potassium levels are a little bit low. And just as a precaution, you know, getting that potassium in
as a supplement is helpful, too, to prevent that level in their blood dropping. And then what about magnesium supplementation? Do you use that as well to help with the leg cramps? Yeah, I think magnesium can be helpful too when it's it it has many I mean it's involved in so many mechanisms in the body including um ball management, uh brain health, right? It's just in everything. And my favorite way of getting people to take magnesium is getting them to eat like half of an avocado every day because not only getting magnesium, you're getting omega-3 and
vitamin E and fiber and um other nutrients. Um, but you know, if you can't if you don't have access to them or they're super expensive and you'd rather spend it on a supplement, yeah, then take a supplement. It may it may prevent those cramps um and help be helpful in other ways. And now another big one is is just keto flu. Um, and that's probably the most commonly talked about one. Um, so how do you help people understand the risk of the keto flu and how to get through it? Yeah. So, I think I I
tell everybody that keto flu is definitely a possibility, but most of the symptoms are preventable and people will listen because I'll say, "Listen, you could take two weeks off of work and recover from keto flu or you can go to work and deal with some minor stuff." Um, but the symptoms are usually related to mineral loss and dehydration, right? headache, feeling lethargic, muscle cramps. Um, and so taking salt during that process and drinking plenty of fluids is really, really important. I've had some people who've actually experienced hypoglycemia during keto startup. And part of that is
that when they've gone from high carb to very low carb, they're cutting out a whole bunch of calories, right? And when they haven't really learned to increase their fat significantly, they aren't replacing those calories. So, they've had a huge reduction in calories and they can get hypoglycemic. So, it's a good idea to have a monitoring tool, either a continuous glucose monitor or glucose um um meter. And there's some glucose meters that also have ketone um strips that go with them. So those those are pretty common for keto. But uh so it's good good to have
that as a backup or safety net to know is it just a low glucose and that's an easy fix. You just eat, right? Eat some a carb, eat some berries or eat your meal and it'll bring it back up. I think some people are surprised though exactly how much they have to drink and how much salt they have to take because they're they're probably not used to salting their foods, right? they've been told not to salt their foods, that salt is dangerous, but now all of a sudden that they're not getting the the ultrarocessed foods
and the salt from that. They can easily become salt deficient. I know. You know, I it's it's quite a learning curve for some people because I'm telling them, listen, you got to eat fat. They've been avoiding fat all their lives. You got to put salt on your food. They've been avoiding salt all their lives, even though they don't know that they've been getting a ton in processed foods. So, it is it is a huge learning curve. And for this reason, I put together a two-sided little PDF. I'd be happy to share it with you if
you want to use it as a download because I give it out to people. And I worked on this with a uh a dietitian that works in cancer research at UCLA. But we wanted a really uh condensed form to show people these are the symptoms and this is what you do to avoid it. And um it I think it's really that people have to sit down and review this a couple times as they're going through this process to know that most of this really is preventable. Yeah. And and I like little tricks about even like
sipping on pickle juice. Um Yeah. Yeah. As as long as it is like dill pickle juice, right? Not sweet pickle juice because my husband would pick this the sweet pickles and there's a huge difference, right? Dill pickles are fermented. you have to buy them in the refrigerator section. The stuff on the shelves is probably just vinegar and sugar preserved pickles, right? So, there's a big difference there. Uh some people like to use bone broth, you know, that's very soothing. Um another another side effect or adverse effect I think of going through the keto initiation uh
is the emotional change that people go through. And I don't think this gets talked about a lot, but I do feel that people grieve about certain things. And it's something that I bring up that I noticed that um you know, people don't offer this, but if I bring it up like you want to talk about how hard it is to give up, you know, certain things that were your comfort foods, you know, that a lot of people will eat ice cream at night before they go to bed. That's a that's a huge habit here in
the Midwest. Um that, you know, most people have been doing that since childhood. And then all of a sudden like what do I do instead of ice cream? What about my glass of wine? You know, like these little things they have to either find a substitute for, which which is what I recommend. Like we got to find a substitute for you to help you get over this. Um or they're just sad about it for a long time, which is, you know, that that does not helpful, right? Yeah, that's a great point. I love the idea
of finding a substitute. Like not saying too bad, you just have to do without it, but instead helping them find something else. you mentioned like fat bombs or or other just sort of low carb or more natural snacks that they can have instead or or even just like you know some some fizzy water some salt water to just to give them something pleasant in their mouth and yeah there are lots of other options so I think that's good fellow mental health clinicians and healthcare providers you now have access to a suite of free CME lectures
on metabolic psychiatry and metabolic health each of these CME sessions provide insight on incorporating metabolic therapy therapies for mental illnesses into your practice. These CME sessions are approved for AMA category 1 credits, CNE nursing credit hours, and continuing education credit for psychologists, and they're completely free of charge on myc.com. Now, back to the video. Now, a lot of people also have concerns about how ketosis is going to affect their exercise performance or their athletic performance. And personally, I think this is a challenging one to talk about because are we talking about the person who's walking
for a half an hour a day or going to the gym or the person who's doing high-intensity interval training or the person who's competing and trying to be at the the top end of performance, right? There's this whole spectrum where we talk about exercise performance, but how do you counsel people about exercise and ketosis? Yes. I have them get Jeff Bolic's book because he wrote a really great book about keto for the athlete. I'm blanking on the name at the moment, but I know you can Google his name and and athlete and you'll find it.
Uh but um yeah, this is this is one that I think uh people kind of have to sort out on their own because I've seen such variations in and remedies for um what people have done. Um just for the casual exercise person, you know, of course, what I emphasize are all the things we talked about with keto flu. You've got to increase your fluids and you've got to increase your your minerals. And for them, you know, I think really they're the ones that need to take an electrolyte supplement because um to get all the salt
and you know, was it potassium chloride, magnesium, just take an electrolyte salt in your beverage and then you're going to get both things in one. Um particularly for people in warm climates, uh who are persspiring but may not, you know, get look sweaty. Um, but the other thing is our energy and and I think this is the part that people really have to figure out on their own. I I have people that feel like they have to have a snack while they're doing any kind of endurance activity. Um, it's almost like carb loading. They but
they're not carb loading because they're doing keto. So like fat bomb loading, right? To keep their energy up and and I it's they're just burning up a lot of energy. they need and if they're lean, they really need just more calories and most of that's going to be fat, but also some protein is good uh and and carb. And I have lots of recipes to guide them to. The TR Foundation has great recipes for fat bombs, and some of them are savory. They're not all sweet. Um but yeah, it it really depends on how long
they're doing the exercise, how intense. I'm I'm working with a guy who um was going to be a uh football player and and then he decided not to and he's he's like a linebacker sized guy and keto was really helping him with his mental health. Um and he started losing a lot of weight. I kind of mentioned him before. He started lo losing a lot of weight. I'm like listen guy you got to eat more calories. you're just losing this too fast and I don't want you to be burning through your lean muscle. In fact,
he wanted to build muscle. So, um for him, our solution was to take an um essential amino acid supplement in a in a like beverage once a day just to make sure he's getting his amino acids um on top of his keto meals. So, he was doing that before he went and did weights. And there's some research to show that that's really beneficial for, you know, muscle um tissue to have a a dietary source of of amino acids soon before you exercise. So that was a solution for him, right? And that that's not something I
usually recommend to anybody, right? But I think you often do hear, you know, oh, it's been proven that keto reduces athletic performance. And I think as you're saying, it's just much more nuanced and detailed than that. And you can't just make that statement. And Dr. Volic's book, The Art and Science of Low Carbohydrate Performance, is a is a great resource to start with, for sure. So, one concern with ketogenic diets is what happens to uric acid and with uric acid, the risk of of gout or kidney stones. Um, so what's your experience with that? So
I definitely have seen uric acid levels go up and this is in pediatrics where we were doing regular blood work and we would you know find out all these things that we had to go on a fishing trip to you know learn why is this happening. Um I have never seen uric acid kidney stones. I have seen the calcium type kidney stone with um medications that can cause kidney stones to pyramate zenismide that I mentioned before. Um, so again with great caution if I see those medications on anybody's intake form, my flag goes up and
I discuss, you know, like this could be a uh situation where we need to talk to your doctor about potentially reducing those medications um or just getting evaluated. I I did have one child who was on one of those medications. He was on to pyramate. We started keto and within a week the parents were calling saying he is screaming in pain and they brought him in and they did a scan. His his um bladder was full of stones and they had been sitting there. It's just that with the increased fluid for keto that I was
pushing now the stones were moving and that's where the pain was. He's he was in excruciating pain from trying to pass a kidney stone. So the diet didn't cause the stones. They were already there. We certainly, you know, just precipitated the pain by increasing his fluids, which may have prevent if he was doing higher fluids before it, they may have prevented the stones. So um yeah, I think those are both really good perspectives about the the uric acid and then about the the kidney stones in general that other causes we have to be very very
aware of. Um, and it's common for uric acid to go up, albeit transiently, and then and then come back down. And that doesn't seem to lead to a higher risk of gout. So, yeah, really interesting perspective about, you know, not people will just react and say, "Your uric acid is up. That's dangerous." Well, hang on. Is it or is it a normal compensatory mechanism that's all going to work itself out? And when you see, you know, hundreds or thousands of people with a ketogenic diet like you have, I'm sure that's something that comes up frequently.
Yeah. And uric acid can just go up with fasting, right? On its own can go fasting. So, you know, that's that's just uh a mechanism your body is breaking down maybe a little bit of protein of its own protein. When you're in a fasted state, it causes the uric acid to go up. You're not, you know, not at risk for anything because it's going to compensate. It's going to come back down. I want to touch on a couple more here in in the time we have left. So, so one that when I read I just
have to do the the palm on my forehead that it will lead to a ketogenic diet will lead to social isolation and eating disorders. That's uh that gets a chuckle out of me, but I come from the perspective of, you know, working with people with this every day. So, so what how do you react to that? Yeah, I mean you do have to develop a thick skin when you're you're doing your diet, but but keep in mind that probably 50% of people are on some kind of special diet due to an allergy intolerance, etc. So,
it's not that unusual anymore to be on a diet. And and I think and this this is again a good conversation to have with when I work with somebody is like let's talk about how you're going to handle family situations because you need to let them know and you need to be know firm and assertive about about it because somebody might want to sabotage you what you're doing by bringing you something sweet or you know something you can't have. Um, and then about eating disorders, we're actually finding that a ketogenic diet can be very beneficial
for uh treatment resistant anorexia nervosa and other kinds of eating disorders. So there's I I was involved with a pilot of uh five women. This is published and that led to a study at UCLA in teenagers. So there's some um important work being done on changing the metabolism of people who have an eating disorder and and it's very probably very similar to other mental health disorders where the brain functions. It can function beautifully with some ketones and behaviors can change. So I I would not be I've never seen any of the children that I've worked
with develop an eating disorder. I know people have worried about it. That's one of the things that parents will ask like, you know, what's going to happen to my kid when we're off this diet? Are they going to be able to eat carbs? And of course, they're going to be able to eat carbs. They won't refuse them. And and you know, I've never seen any child develop an eating disorder because of being on strict keto. Even the 90% fat keto, we've not had this this issue at all. Yeah, that's such a good point about the
about the eating disorder and not being connected. Um, and then the social isolation part. I I I really like what you said that you know probably half the population is on some form of a special diet. So why would this diet be any different for social isolation than others except that the stuff that we know we shouldn't be eating like the the processed than the sweets and the desserts and and all that the stuff we know we shouldn't be eating that is unfortunately such a part of society um that you know how can it be
abnormal to say no thanks I I don't want to eat that. Right? That just says so much about our society as well. It's disturbing in so many ways. Maybe maybe just to say, you know, if if you are undertaking a ketogenic metabolic therapy and you live with people, um it's a good idea to talk to them about it either before you start or while you're on it to share why you're doing this. And I think what people usually find is that other people will be more supportive and they may even join you. Um, and if
they don't want to join you, they may help you by preparing things that like keto bread or you know if if anyone says, "Can I do anything for you?" Give them the recipe for keto banana bread or something because if people are truly willing to support you, they'll love to do that for you. And I've seen that happen many, many times where, you know, people are kind of doing this on their own and sort of feeling burdened by living in our culture that does not cater to a low carb diet. Um, and they can use
some help, right? So, don't be afraid to ask people around you to help you. So, an another thing that I hear that is maybe a misconception is that keto is just an excuse to eat bacon and butter. And if you want to be in ketosis, you got to eat your steak, you got to eat your bacon, you got to eat your butter. How do you respond to that? Yeah. So that that's a total myth. And u I have very few people that eat bacon regularly. Maybe steak regularly, but maybe not bacon. So let me step
back and just say ketogenic diets really refer to the macronutrient distribution of a diet, the fat, protein, and carb. we can style that diet to somebody who's carnivore, somebody who's vegetarian, even vegan. It's a little harder, but we can do it. Um, or Mediterranean. That's more of a popular approach. But when people come to me, they don't usually name the style of diet they're on. It really not necessary to name it. Um, I do an intake on people. I want to see what they eat over a course of three days. and I might notice that
they're not eating red meat, but I don't have to say, "Oh, you're vegetarian or you're partially vegetarian." I just work with whatever their preferences are, their food allergies, and tolerances, you know, making sure that I know what that might be. And these days, it seems like almost everybody has something that they can't tolerate or that uh just doesn't agree with them or that they don't like. So you see it can be applied to really any diet even even halal kosher um allergies we can make it gluten-free casein free the classic ketogenic diet was gluten-free just
by nature of being so low carb it was gluten-free so that's you know been used over a hundred years uh but we really can tailor it to any allergy diet style intolerance preference um and and make it in an individual therapy that you works for that person. Yeah, it's a great perspective. It's any diet that gets you into ketosis and it doesn't have to be one way, but can be so many different ways. And I really appreciate that perspective. I think this has been a really good discussion about a number of concerns that people see
online or hear about ketogenic diets. and your perspective is so helpful that that maybe some of these we need to think about and address, but a lot of them are sort of misunderstandings of of what a ketogenic diet is and how people respond to it. But so important to get educated by somebody like you who is an expert in this and has been doing it for for so long. Um, so before we go though, you know, a couple last questions like where can people follow you to learn more and are there other resources you you
like people to you like to send people to? Yeah, so I have to say I don't have a large social media presence only because it's like beyond my ability to do that on top of maintaining a couple large databases. I I help manage the Charlie Foundation website. I have a keto diet calculator platform for calculating medically used ketogenic diets and it just just one more thing that I I would not be able to stretch myself to. So I don't have a large uh social media presence. I do have a website and it's just my name
Beth Zupetania. Um, and I think uh, Metabolic Mind is one of my favorite uh, websites to send people to because it's you it's really a beautiful website that they've developed and they keep adding resources to it. You'll find me on there somewhere. Um, and Georgia E has a website. Uh, Chris Palmer is a a psychiatrist as well who people need to know about and follow. um Matt Bernstein, who also is not very much on uh social media, but he's another um trailblazing psychiatrist. He's actually joining me at a conference for dietitionians this uh fall, October
12th, to speak to the American Dietetic Association group about keto for mental health. So, he's gonna, you know, he's going to be blasted all over social media platforms in in the nutrition world. Um, so yeah, those are the off the top of my head some great resources. There's a lot of keto cookbooks out there. Um, however, I'm sort of disappointed that many of them are low carb or they're not necessarily keto. Uh, yeah, but um I think wait for mine. My book is coming out soon. Well, that's great. I can't wait for that. We'll be
happy to to um to promote it. And um you know, those names you mentioned are are certainly some of my favorites and and some of the trailblazers really putting out great information and we're happy to to share all their information. But as with you, I mean, just such a pleasure to have any opportunity to talk to you and tap into your wisdom and your experience. So, thank you so much and and I look forward to to meeting up with you again. Oh, you're so welcome. Thanks for having me.
