Did you read our article on Keto 101: The Ketogenic Diet for Beginners, and now feel ready to take your knowledge base to the next level? If you are familiar with the basics of keto and think it might be an appropriate approach to help you with healthy weight management, this article will help to answer any questions that you may have.
Before we begin, it is important to mention that weight loss is not a healthy goal for every person. People with a history of eating disorders, children and adolescents, pregnant and breastfeeding women, those who are underweight or already at a healthy weight, and those with certain medical conditions should not attempt to lose weight outside of a medically recommended and supervised program.
Here are the common questions about weight loss and keto that we’ll tackle in this article:
- What are the diagnostic definitions of overweight and obesity?
- Which interventions are considered evidence-based for weight loss?
- Why are some mainstream healthcare providers hesitant to suggest ketogenic diets as a weight-loss approach?
- Do you have to track macros to lose weight on a ketogenic diet?
- Does it ultimately matter whether you choose “clean keto” versus “dirty keto”?
- What are the three major pitfalls that people face when utilizing the ketogenic diet for weight loss?
What are the diagnostic definitions of overweight and obesity?
Making radical changes to diet and lifestyle may not be the best approach for those who are in a healthy weight range or slightly overweight but looking to lose a little extra body fat (i.e., “vanity pounds”). For the people who fit this category, simply adding a little more physical activity in and making small changes to increase dietary quality may be all that it takes to help them meet their health goals.
On the other hand, those who fit the diagnostic criteria for overweight or obesity may need a more dramatic diet and lifestyle overhaul to best help them meet their weight loss goal. Dietitians typically use the Body Mass Index (BMI) to diagnose overweight or obesity. You can calculate your own BMI status by entering your height and weight into the CDC adult BMI calculator at this link.
BMI results for adults (defined by the CDC as age 20 or over) are generally interpreted as follows:
- < 18.5 is underweight
- 18.5-24.9 is considered a healthy weight
- 25-29.9 is overweight
- ≥ 30 is obese
Though BMI may be a good starting point for some to determine whether a weight-loss intervention may be appropriate, it is not right for everyone. A caveat to using BMI is that it does not distinguish between high lean body mass and high body fat, making this an inappropriate tool to assess the health status of muscular athletes. The waist-to-height ratio may be a better predictor of health and longevity than BMI, though it tends to be less commonly used.
Which interventions are considered evidence-based for weight loss?
It seems so simple on the surface; just eat less and move more to lose weight, correct? In reality, this over-simplified advice is similar to telling people that they can get rich by spending less and earning more. (Not so easy, is it?) So, while the ultimate goal in weight loss is to create a calorie deficit, focusing primarily on the calorie content of foods is not the right approach for every person who would like to lose weight.
For those that are overweight or obese, there are actually a variety of strategies that may help in the reduction of body fat. The Academy of Nutrition and Dietetics published a position paper in 2016 which listed the weight-loss interventions that are currently considered evidence-based. What follows are the interventions that were “investigated using RCTs with evidence considered supportive for weight loss”:
- Decreasing sugar-sweetened beverages (e.g., soda, energy drinks)
- Portion control
- Low and very low-calorie diets (including high-protein, DASH, and Mediterranean diets that have been combined with calorie restriction)
- Meal replacements and structured meal plans
- Low-carbohydrate diets
This paper states that “A low-carbohydrate diet is commonly defined as consuming no more than 20 g of carbohydrate per day… Once the desired weight is achieved, carbohydrate intake can increase to 50 g per day.” It is recognized that 20-50 grams of carbohydrate per day are a level that induces nutritional ketosis; thus, a ketogenic diet may be considered an evidence-based weight loss method.
Why are many mainstream healthcare providers hesitant to suggest ketogenic diets as a weight loss approach?
Even though the weight loss interventions listed above are all evidence-based, that doesn’t mean that they are all equal in terms of what is best for a particular individual. In addition, certain weight loss intervention strategies are more likely to be suggested by mainstream health practitioners than others. Ketogenic diets are often not offered as an option to patients other than as medical nutrition therapy for intractable epilepsy.
One of the main reasons that many health practitioners are hesitant to suggest the ketogenic diet for weight loss is that the diet has people consuming well below the Recommended Dietary Allowance (RDA) of carbohydrates for adults, which is 130 grams per day, a level set “based on its [carbohydrates] role as a primary energy source for the brain.” However, the American Diabetes Association recognizes in a 2019 consensus report that the brain’s glucose requirement, “can be fulﬁlled by the body’s metabolic processes, which include glycogenolysis, gluconeogenesis, and/or ketogenesis in the setting of very low dietary carbohydrate intake.” Consuming at least 130 grams of carbohydrates per day is not an essential requirement for life for most individuals.
Carbohydrate is not the only macronutrient that is typically pushed outside of the Acceptable Macronutrient Distribution Range (AMDR) on a ketogenic diet, fats are as well. It is generally recommended that adults keep fat intake to 20-35% of their total calories, but a person on a ketogenic diet may be consuming anywhere from 60-90% of their calories from fat. The current thinking is that if “an individual consumes in excess of the AMDR, there is a potential of increasing the risk of chronic diseases and/or insufficient intakes of essential nutrients,” something health practitioners would like to protect patients against.
Unfortunately, we don’t currently have a widely used way to match those who want to lose weight with the approach that might work best for them. If you have tried the other approaches to weight loss without success, and are comfortable with the long-term concerns regarding the ketogenic diet, consider consulting with a physician or dietitian who is supportive of and has experience with helping others with this way of eating. Having a professional on your team can help you to plan a well-formulated diet and avoid the common pitfalls.
Do you have to track macros to lose weight on a ketogenic diet?
While some may choose to track their macronutrients on a ketogenic diet for weight loss, many feel that an advantage of a very low-carb diet over other approaches (such as a low-calorie diet) is that they do not have to track diet intake. What is most important is being attentive to your personal satiety level on the ketogenic diet. This is in agreement with recent suggested clinical guidelines for carbohydrate restriction, which stated that “In counseling, the emphasis should be on foods and general carbohydrate restriction, rather than monitoring macronutrient content.”
Unlike carbohydrates, certain amino acids (from dietary proteins) and fatty acids (from dietary fats) are essential for humans, and not consuming enough of these components can lead to negative consequences. For sedentary adult men, the Dietary Reference Intake (DRI) for protein is 56 grams per day, and for sedentary adult women, the DRI is 46 grams per day.
The DRI for protein represents the lower end of what you should aim to consume, and for most healthy adults with weight loss as a primary goal, there is no disadvantage to consuming more. Protein is considered the most satiating macronutrient in the scientific literature, leaving people feeling fuller longer than carbohydrates or fats, though some individuals may report that they find another one of the macronutrients to be the most filling. Though it has been recognized that higher protein intakes “may impact the ability to maintain ketosis,” the level of protein that may push a person out of ketosis varies by individual and should be weighed against the benefits of consuming a higher protein diet.
Though most adherents of the ketogenic diet are consuming more than the recommended levels of fat that are needed to be healthy, it is important to be aware that consuming excessive amounts of protein in the near absence of fat can be detrimental. There is a condition called “rabbit starvation syndrome” that befell early explorers who attempted to subsist solely on very lean wild meat. If the liver cannot upregulate the synthesis of urea to meet large protein loads, unpleasant gastrointestinal symptoms and eventually (if no diet changes are made) death can result.
In short, no, you do not necessarily need to track your macronutrients on a ketogenic diet. However, it is crucial to ensure adequate intake of both protein and fat.
Does it ultimately matter whether you choose “clean keto” versus “dirty keto”?
While those choosing “clean keto” are attentive to both their macronutrient intake and their diet quality, those on “dirty keto” focus only on keeping carbohydrate intake low. While it might seem desirable (at least initially) to live on a diet of low-carb desserts and ultra-processed substitutes for your favorite high-carb foods, the truth is that diet quality matters, no matter which way of eating you subscribe to. Not only do you run a higher risk of vitamin and mineral deficiencies with “dirty keto” by displacing healthier food choices, but you may also inadvertently be sabotaging your weight loss efforts.
A 2015 study found that all of the foods reported to be most addictive were a combination of fats and carbohydrates (typically in the form of refined flours or added sugars). All of these foods are restricted (or modified) in the ketogenic diet. The top 10 addictive foods were found to be:
- Ice cream
- French fries
- Buttered Popcorn
Avoiding all of the above foods on a ketogenic diet may make success more easily achievable because these are foods that people find very easy to overeat. On the flip side, including a lot of keto-friendly substitutions for desserts and snack foods in the diet may end up becoming a barrier to reaching your goals.
The demand for keto-friendly cookies, cakes, ice cream, fat bombs, etc. has created an influx of these expensive products in the market. Unless a small amount of these products are helping you to overcome a craving, I recommend saving your money and sticking primarily to a diet of minimally processed whole foods.
What are the three major pitfalls that people face when utilizing the ketogenic diet for weight loss?
- Not having the support of a medical professional who is familiar with the ketogenic diet and can help you formulate a nutritionally sound plan. Your needs for certain electrolytes (Na, K, Mg) may be altered with the change in macronutrient intake. Get a professional to help you optimize this way of eating.
- Not getting baseline measurements, so you can see how this diet is impacting your body. Refer to the Keto 101 article for specific labs to get checked.
- Overconsuming high-calorie keto foods such as butter coffee, cheese, and nuts. Reducing some of these keto-friendly but easy to overeat foods and increasing protein intake may help you to feel more satisfied.
The weight management strategy that will ultimately be best for you will help you to feel satiated while maintaining a caloric deficit (or calorie balance, if you are already at a healthy weight). Some people report feeling better on a ketogenic diet and that they prefer this way of eating, both factors that may help them to sustain the diet over the long-term.
Do you feel like keto might be the right approach for you? Be sure to check out our ketogenic diet recipe section. We have plenty of health-promoting and tasty ideas that will quickly become your new favorites!
Summer is a registered dietitian located in Avon, Connecticut where she specializes in weight management, special diets, general nutrition, and avoidant/restrictive food intake disorder (ARFID). She is the developer and content creator behind the Summer Yule Nutrition website, where she shares evidence-based information on hot topics in food and nutrition.