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Biohacker's Guide to Ketosis

Biohacker's Guide to Ketosis

Olli Sovijärvi & Teemu Arina BIOHACKER’S GUIDE TO

BIOHACKER’S HANDBOOK: SPECIAL ISSUE

1 Biohacker’s Guide to Ketosis Biohacker’s Handbook: Special Issue Version: 1.0

Publisher: Biohacker Center BHC Inc. PO Box 955 FI-00101 Helsinki, Finland www.biohackingbook.com

© Olli Sovijärvi and Teemu Arina 2019

Visual design, layout and illustrations: Lotta Viitaniemi Advisor and studio critic: Dr. Sam Inkinen English translation: Salla Williams Proofreading: Anne Belott

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission of the publisher.

This guide is based on the personal experiences of its authors, and the advice it contains is based on a combination of experience and scientific research. This guide and the viewpoints that it expresses should not be treated as medical advice. Consult with your doctor before using any methods presented in this book or ordering and using any of the herbs or supplements mentioned in this guide.

2 BIOHACKER’S GUIDE TO KETOSIS

3 HISTORY of per kilogram of body weight, 10–15 grams of , and acquiring the rest of the daily calorie 3 The modern history of the goes back as needs from fat. In terms of macronutrient distribution, this far as a hundred years—it was used in the 1920s to treat is practically identical to the ketogenic diet in medical use 4 patients, with very promising results. The very first in 2019. Western medicine trials using the ketogenic diet to treat epilepsy were carried out in 1911 when two French doctors The ketogenic diet was used successfully for two decades (Gulep & Marie) treated 20 epileptic children and adults after its invention until the treatment of epilepsy was with the so-called starvation technique (). The John revolutionized by medication. Treatment through diet was Hopkins Hospital was the first clinic to treat pediatric largely forgotten. In the past 20 years, the ketogenic diet epilepsy in particular with the ketogenic diet. However, has again become popular. Many clinics for example spe- fasting and ketosis are known to have been a popular cialize in strict dietary treatment of epilepsy. The effects treatment method even in Ancient Greece approximately of the ketogenic diet on many other illnesses have been 2500 years ago. Documentation on the matter can be widely studied. It is increasingly being applied in the treat- found, for example, in the writings of Hippocrates.1 ment of neurological illnesses as well as various metabolic illnesses. In 1921, a scientist by the name of Woodyatt discovered that fasting or eating a low- diet caused the However, the main indication and secret of the ketogenic body to produce and beta-hydroxybutyrate.2 That diet lies in the very effective and the same year, Dr. Wilder from the Mayo Clinic defined the activation of it offers. Because of this, the term “ketogenic diet” based on this mechanism. This early popularity of the ketogenic diet has increased exponen- version of the ketogenic diet involved eating one gram tially within the past few years (see image on next page).

4 THE POPULARITY OF “KETOGENIC DIET” INTERNATIONALLY, ACCORDING TO GOOGLE TRENDS

THE POPULARITY OF “KETOSIS” INTERNATIONALLY, ACCORDING TO GOOGLE TRENDS

5 KETOSIS everyday lives have caused us to develop in the wrong direction: the sensation of hunger and fasting have Ketosis refers to the metabolic state in which become rarer and there are more obese people now bodies (and not ) form the body’s primary energy than ever before. source. Ketosis takes place when the consumption of carbohydrates has been repeatedly restricted to less than Ketosis is induced incrementally after 3–4 days of low 50 grams per day, or the overall energy consumed is less calorie intake, fasting or limited carbohydrate intake than 800 kcal per day (very low calorie diet, VLCD).5 6 once the body’s glucose stores (mainly in the Assuming that the metabolism is functioning normally, and some glycogen in the muscles) are depleted. the body enters a mild state of ketosis after a night’s sleep The activation of ketosis is a normal bodily reaction to (8 hours). The slow onset of ketosis after fasting is also secure the energy supply of the central nervous system 8 9 directly proportional to abdominal obesity. The more and the brain when no glucose is available. obese the individual, the slower the onset of ketosis.7 The so-called keto flu is a common condition resembling Ketosis is very natural for the body and part of normal the common cold, caused by the homeostasis of energy metabolism. In other words, our bodies are “designed” metabolism shifting from burning glucose to burning to burn fat for energy and to store excess energy in the mainly fat. The fatigue, headache and irritability associated . The process is highly functional, particu- with the keto flu, as well as any muscle cramps, are usually larly when there is insufficient energy available from food. caused by the loss of fluids, electrolytes, and glycogen. Throughout evolution, ketosis and the activity of lipid These symptoms are also signs that the body is not yet metabolism have played a key role in human survival. utilizing fats efficiently nor using the resulting ketone 10 11 On the other hand, ketosis has not always been the bodies effectively as an energy source. The default metabolic state in humans. The development production in the body is also significantly diminished of agriculture, the constant availability of food, food with the lower carbohydrate intake, causing increased 12 advertising, and simply the presence of food in our sodium excretion into the urine.

6 THE ABSORPTION AND DELIVERY OF FATTY ACIDS IN THE BODY

The keto flu can be prevented by consuming plenty of electrolytes (particularly sodium, potassium AcylCoA and magnesium) and salt (such as sea salt) during the initial phase LCFA of ketosis. If you feel faint, drink plenty of fluids and electrolytes MCT LCT Chylomicron (including salt). The keto flu is MCFA typically less severe or non-existent Lumen when the ketosis follows a relatively MCT low-carbohydrate diet (less than Intestinal mucosa 150-200 g/day). Avoid heavy exercise during the first few days. The intake of diuretics (such as Fatty acids LCFA coffee) should also be limited.

Lipids CO2 The onset of ketosis may be Liver Peripheral tissues accelerated by consuming medium-chain fatty acids (MCT Note greater efficiency in absorption MCTs versus LCTs. oil).13 Compared to long-chain fatty acids, MCT fatty acids are Source: Ward, D. & English, J. (2013). Medium chain (MCTs). Beneficial effects on energy, atherosclerosis and aging. Nutrition Review. very rapidly used for energy due to being readily absorbed (see image). MCT fatty acids also move quickly into the be activated after intense and prolonged exercise, mitochondria and (unlike long-chain fatty acids) they particularly if only a small amount of carbohydrates was do not require carnitine to oxidize fats. Ketosis may also consumed before such exercise.14

7 THE FASTEST WAY TO ACHIEVE KETOSIS:

1. Before starting a ketogenic diet, slowly begin to 4. Drink plenty of fluids and add high-quality salt to limit your intake of carbohydrates. For example, both food and drinks; electrolyte sachets may cut out all cereal products and replace them with prevent keto flu symptoms almost entirely. vegetables, berries, and fruits. 5. Walking activates and helps the 2. After 2–3 weeks, limit the intake of carbohydrates body switch from burning sugar to burning fat. to less than 50 grams per day (you will achieve even better results and a faster ketosis if limiting 6. Intermittent fasting significantly accelerates the them to less than 20 grams) – the term “carbo- onset of ketosis (see the section on intermittent hydrates” here refers to the carbohydrates that fasting). impact the blood sugar levels (net carbs), not fiber. 7. Limiting energy intake accelerates the onset of 3. Increase the intake of high-quality fat (for example ketosis; however, extreme calorie restriction/ olive oil, avocado, butter, coconut oil and hemp extremely low-energy diets are not necessary or oil, as well as the fat occurring naturally in animal recommended. products) whilst reducing the intake of carbo- hydrates; however, note that the energy content 8. The fastest way to ketosis is a 3–4 day liquid fast of one gram of carbohydrates (4 kcal) is equivalent after which the body is in a deep state of ketosis; to roughly half a gram of fat (1 gram of fat = however, this requires more willpower and approximately 9 kcal). perseverance than other methods.

8 Fasting or restricting the consumption of THE BIOCHEMICAL REGULATION OF KETOSIS carbohydrates decreases insulin levels in the circulation whilst increasing the levels 15 of and . This leads to the release of free fatty acids and glycerol Glucose sensitive lipase (beta-oxidation) into the circulatory system. NEFA + glycerol Oxidized fatty acids and glycerol form into Phosphoenolpyruvate acetyl-, which in turn enters the Fatty acyl-CoA cycle in the mitochondria (see Pyruvate section “Metabolism—the Cornerstone of Acetyl-CoA Energetic Life” in the Biohacker’s Handbook Exercise chapter for more information). x Citrate TCA 2 Acetyl-CoA The production of is activated cycle by the excessive production of acetyl-coen- Oxaloacetate Acetoacetyl-CoA zyme A. The process is activated when all the malate has been has been used for Acetoacetate and there is insufficient amount of oxalo-acetate available for the Acetone Beta-hydroxybutyrate normal (compared to a situa- tion in which carbohydrates are continuously During high rates of oxidation, primarily in the liver, large amounts of available). Acetyl coenzyme A is used to form acetyl-CoA are generated. These exceed the capacity of the TCA cycle, and one result is the synthesis of ketone bodies. aceto-acetate and in particular beta-hydro- xybutyrate (BHB), the primary ketone body (see image).16

9 The ketone bodies produced by the liver are released into on mice (2019) indicated that the ketogenic diet increases the circulation and delivered into the mitochondria of the the volume and mass of mitochondria via the PGC1α- brain, internal organs, and muscles for use in energy SIRT3-UCP2 path.20 This may explain why individuals who production (ATP). BHB is recycled again into acetyl are in a state of ketosis often indicate that their attention coenzyme A, which is utilized in the citric acid cycle.17 span and mental agility have improved significantly.

Insufficient research exists to assess the safety of extremely Potential health benefits of ketosis:21 22 23 prolonged ketosis. On the other hand, the longest- • An effective weight loss method, particularly in the short ranging study conducted to this date involved 56 weeks term of continuous ketogenic diet, which in and of itself is a • An effective method in the treatment of epilepsy relatively long time as far as scientific research goes. This • Facilitates mitochondrial function and reduces oxidative study found ketosis to be beneficial for the health of stress in cells overweight individuals.18 At the same time, from an • May reduce the risk of cardiovascular diseases evolutionary standpoint, it is not typical for human beings • May reduce the risk of developing ; may to remain in continuous ketosis for extended periods of be helpful in the treatment thereof time. Rather, after fasting or food acquisition, the energy • May help treat deficit is normally corrected. • May be helpful in the adjuvant therapy for cancer • May help treat polycystic ovary syndrome Studies conducted on rats indicate that ketosis increases • May help treat degenerative neurological diseases (such the biogenesis (volume) of mitochondria and boosts the as Alzheimer’s disease and Parkinson’s disease) production of ATP, particularly in the brain.19 A recent study

10 MEASURING KETOSIS test strips cost several euros each) and the constant finger pricking. The price of the device is between 20 and 50 Ketosis produces three main ketone bodies: acetone, euros. Good quality devices include CareSens Dual Blood acetoacetate and beta-hydroxybutyrate. All three ketone Glucose and Ketone Meter and Freestyle Precision NEO bodies can be measured using various methods. The most Blood Glucose Monitoring Meter. Ketone body test strips commonly used method is to check the levels of beta- for these devices are available, the prices of which vary hydroxybutyrate (BHB) in the blood. Another popular between 3–4 euros per strip (usually sold in packs of 10). method is to measure the amount of acetone in the breath.

A third method is to measure the acetoacetate levels in the KETONE BODY LEVELS KETOSIS STATE OF urine. Of these, the BHB levels in the blood are considered IN THE BLOOD THE BODY the most accurate, particularly for monitoring changes in the ketone body production in the early stages of ketosis.24 < 0.2 No ketosis

Measuring is not absolutely necessary. However, it does 0.2–0.5 Mild ketosis provide a measurable indication of the activation of ketosis and may give a morale boost to continue with the diet, 0.5–3.0 Ketosis caused by food especially in situations where the motivation is low. consumption

1. MEASURING KETONE BODY LEVELS IN THE BLOOD 2.5–3.5 Post-exercise ketosis Ketone bodies (BHB) in the blood are measured the same way as blood sugar levels, with a finger prick test. A special 3.0–6.0 Ketosis caused by device can be used to measure both blood sugar and starvation ketone body levels from a drop of blood extracted from the fingertip. The measurements are generally very 15–25 accurate. The downsides are the high ongoing cost (the

11 PHASES OF KETOSIS Source: Phinney & Volek (2011). This testing method is effective especially when starting out with the ketogenic diet and monitoring ketone body levels. Most people reach mild ketosis (0.5–1.0 mmol/L) within a few days and deeper ketosis (1.5–3.0 mmol/L) within 2–4 weeks.25 The further the progress of keto-adaptation whilst adhering to the ketogenic diet, the Optimal more efficient the use of ketone bodies ketone for energy supply. This in turn leads to a zone dip in the BHB levels in the blood, and Post-exercise ketosis often significantly lower readings are seen compared to the first few weeks on the

Optimal fuel flow for brain and muscles Nutritional Starvation ketogenic diet. This is completely normal. ketosis ketosis begins Ketoacidosis // // 2. MEASURING KETONE BODY LEVELS IN 0 0,5 1,0 1,5 2,0 2,5 3,0 5,0 10+ THE BREATH If poking your fingers with a needle is not Blood (nmol/l) your idea of fun, there are several devices on the market that measure acetone in the breath. Out of all ketone body molecules, acetone is by far the smallest in size and thus excreted via accurate method of assessing ketosis, as long as the test is the respiratory system. This in turn makes it possible to always repeated in the same way and the device has been measure ketosis by analyzing respiratory gases. Measuring carefully calibrated for the air in the room.26 Acetone levels the acetone in the exhaled gases has been found to be an can also be compared to the BHB levels in the blood.27

12 A study published in 2018 found breath analyzers to be a 3. MEASURING KETONE BODY LEVELS IN THE URINE reliable method of assessing the state of continuous Measuring ketone bodies (more specifically acetoacetate) ketosis in healthy individuals adhering to the ketogenic in the urine has been possible for some time now. It is diet, as well as for those suffering with epilepsy.28 used especially in healthcare when the urine is checked for Measuring acetone levels in the breath can also be glucose, ketone bodies, or protein. However, the ketone used for weight management and monitoring fat burning bodies in the urine are not so much indicative of ketosis, in those adhering to the ketogenic diet.29 rather they indicate the level of excess ketone bodies being excreted from the body. Thus, particularly in the In the light of this information, breath analyzers are a very early stages of ketosis, the level of ketone bodies in the good, convenient method for monitoring the ketogenic urine is usually high, as the body has not yet keto-adapted. diet in the long term, particularly when the goal is weight This method is, of course, useful for monitoring the onset loss or the prevention of epileptic seizures. of ketosis. As the keto-adaptation/fat-adaptation progresses, the ketone body levels in the urine usually decrease as the The earliest and most widely used acetone meter on the ketone bodies are being efficiently used for energy in the market is the Swedish-made Ketonix, which has been body. found to be a very effective and reliable device. The urine testing is typically used to assess ketoacidosis in diabetic individuals,30 especially when the finger prick test is not available.31

13 KETO-ADAPTATION (FAT-ADAPTATION) The typical keto-adaptation process is as follows, AND INCREASED FAT BURNING assuming no previous experience or adaptation to the ketogenic diet: The activation of ketosis is the first phase of keto-adapta- tion. However, it takes quite a while for the body to learn 1. Potential withdrawal symptoms caused by restricting to run effectively on fats. This phase and process is called carbohydrates and sugar are often accompanied by keto-adaptation (or fat-adaptation). Ketosis and keto- withdrawal symptoms from morphine-like compounds adaptation are therefore not synonyms, nor are they found in cereal products (such as gluteomorphin)33 as mutually exclusive. Ketosis is usually defined as a meta- well as sugar.34 bolic state where the ketone bodies in the blood exceed the level of 0.5 mmol/L. Keto-adaptation on the other 2. Potential keto flu and the associated symptoms (see hand refers to the body learning to efficiently use these above) can be reduced by consuming electrolytes; ketone bodies as an energy source. however, some of the symptoms will remain until the brain learns to efficiently use ketone bodies as an energy source. Keto-adaptation usually takes approximately 2–4 weeks; however, full adaptation often only occurs in the several 3. The use of ketone bodies as an energy source is boosted months following. Studies typically define three phases when the biochemical steps of lipid metabolism are of keto-adaptation: activated and intensified (including increased mono- carboxylate-1 receptors on the cell membrane as well • Short-term adaptation (7–14 days) as increased carnitine palmitoyltransferase and • Medium-term adaptation (14–35 days) carnitine-acylcarnitine translocase production).35 • Long-term adaptation (2–12 months or longer) 4. When the adaptation phase has progressed for about The progress of keto-adaptation and its impact on a month, the individual usually notices improved perfor- performance has been widely studied, particularly in mance in endurance exercise, clearer thinking, improved endurance athletes.32 regulation of hunger, and overall higher energy.

14 5. After several months of keto-adaptation, the individual is • Low appetite (typical as the body begins to use its own usually able to fast for extended periods without an fat deposits for energy) obvious sensation of hunger or impaired performance • Fatigue, headaches and faintness (linked to the brain – intermittent fasting becomes significantly easier. “practicing” utilizing ketone bodies)

6. The final crucial phase ismetabolic flexibility, i.e. the Once there has been clear progress in keto-adaptation, body is able to efficiently use both fats and glucose as the following changes in the body are usually apparent: energy sources – this adds flexibility to the diet as • Balanced blood sugar regulation – no major swings in incidental carbohydrate consumption does not upset blood sugar levels the metabolic balance or “throw the body out of ketosis”.36 • The blood sugar levels are typically even hypoglycemic (3.0–4.4 mmol/L), yet the individual feels energetic, clear Metabolic flexibility is the ideal metabolic state in which and sharp the body runs efficiently on any “fuel”. • As for lab results, HbA1C () is usually lower; in the keto-adapted state it is typically Symptoms associated with the keto-adaptation phase around 4.5–5.2 % include: • Clarity of mind and thinking (efficient use of ketone • Keto breath, or the smell of acetone in the breath bodies for energy in the brain) (caused by ketone body production; acetone is a ketone • Constant energy levels regardless of the time of day body which is excreted through respiration) • Low hunger • This is often accompanied by slightly metallic taste in the • Higher endurance in sports (assuming sufficient calorie mouth intake from food)37 • Strong-smelling urine, usually caused by acetone • Improved quality of sleep38 • Strong-smelling sweat, usually caused by acetone • Reduced silent inflammation and the alleviation of • Fluid loss (linked to restricted carbohydrate consumption various complaints39 40 – as glycogen stores are depleted, the water bound to • Reduced muscle catabolism41 the carbohydrates is also lost) • Reduced edema and fluid retention in the body

15 CHANGES OF THE ENERGY SOURCE FOR MUSCLE AND FAT TISSUE IN DIFFERENT SITUATIONS

Fatty acid oxidation Glucose oxidation Glycogen storage

DURING SLEEPING DURING EATING Fatty acid storage

Fatty acid oxidation Glucose oxidation x Glycogen storage

DURING FASTING DURING EXERCISE Lipolysis Fatty acid storage

Lähde: Goodpaster, B. & Sparks, L. (2017). Metabolic Flexibility in Health and Disease. Cell Metabolism 25 (5): 1027–1036.

16 THE MANY FACES OF THE KETOGENIC DIET higher carbohydrate consumption. Individuals adhering to this type of ketogenic diet have found significant benefits, The ketogenic diet does not indicate a single, strictly particularly in terms of exercise.45 Many athletes and defined diet. Instead, there are several “keto variations”. individuals who exercise heavily use this tactic of the This is also reflective of the fact that different people have ketogenic diet. In some cases, once the keto-adaptation different preferred ways of being in ketosis and following (fat-adaptation) has progressed sufficiently, athletes the ketogenic diet. This is completely natural, as we are practice the “carb backloading” method in which carbo- all different – from athletes to couch potatoes, from busy hydrates are consumed in the evening whilst generally workers to retired seniors.42 maintaining the state of ketosis in the body.46

The most common and by far the most widely studied Another popular technique is the targeted ketogenic ketogenic diet is the standard ketogenic diet (SKD). SKD diet (TKD), which involves consuming carbohydrates prior is used in many medical research settings (particularly in to exercise (usually 20–50 grams 30 minutes before neurology). It has also yielded the best-documented exercising, although some scientists only recommend results in treating many illnesses, including epilepsy.43 5–10 grams if the exercise session is shorter than one As the name implies, the standard ketogenic diet hour). The objective is to maximize the energy supply adheres to certain standards of macronutrient distribution when exercising at high intensity. For TKD to be beneficial, and energy supply: 75–80 % fat, 15–20 % protein and 5 % the individual must adhere to the ketogenic diet and carbohydrates. perform plenty of glycogen-depleting exercise (HIIT, sprints, Crossfit, bodybuilding or prolonged sports Another popular form of the ketogenic diet is the cyclical events).47 TKD does not work the same for everyone due ketogenic diet (CKD), which involves carb cycling.44 After to individual variation in the function of glycogen stores, the keto-adaptation phase, the diet involves mainly low fat-adaptation, and the use of various energy sources. carbohydrate consumption and adhering to the ketogenic However, it is an option to consider for individuals who diet; however, for example, once a week there can be exercise a lot.

17 Recommended, mainly glucose-containing Other forms of the ketogenic diet include the high- carbohydrate sources in TKD (real foods): protein ketogenic diet (HPKD), which is especially • Potato popular amongst bodybuilders. The high-protein keto- • White rice genic diet may be a very noteworthy option, particularly • Sweet potato for individuals who have trouble controlling portion sizes • Beetroot (also contains vasodilator nitrates) but still wish to lose weight. This approach is effective due to protein being by far the most satiety-inducing of all Avoid fructose, as it is metabolized in the liver and is macronutrients.48 not useful during exercise (cf. glucose, which is used for energy in the muscles). If you are unable to eat real food For vegetarians, there is also the vegan/vegetarian keto- but you still wish to consume some carbohydrates, pure genic diet. Although significantly harder to execute, the glucose or dextrose (in powder form) is recommended. vegan or vegetarian ketogenic diet is possible with the help of a nutrition coach who is familiar with the topic.49

18 CALCULATING MACRONUTRIENTS FOR To estimate calorie needs/expenditure, you can use the THE KETOGENIC DIET Harris Benedict formula: The easiest way to get an estimation of calorie needs is Macronutrients refer to the three main energy sources: to use an online calculator: protein, fat, and carbohydrates. The percentages of these manytools.org/handy/bmr-calculator in the food determine whether the body will achieve ketosis. A typical standard ketogenic diet contains 75–80 % The formula is used to calculate the basal metabolic fat, 15–20 % protein and 5 % carbohydrates. The most rate (BMR) and any further daily energy expenditure, common distribution is 75 % fat, 20 % protein and 5 % depending on the activity level. carbohydrates. The percentages refer to the distribution of energy, not grams of weight. This is because one The calculation formula (original version) can be found gram of carbohydrates or protein yields approximately below):51 4 kcal of energy, whereas one gram of fat yields 9 kcal, • Men: BMR = 66.5 + (13.75 × weight in kg) + (5.003 × i.e. more than double.50 height in cm) − (6.755 × age in years) • Women: BMR = 665.1 + (9.563 × weight in kg) + (1.85 × The first step in building a personalized diet is to determine height in cm) − (4.676 × age in years) the desired macronutrient distribution (for example 75/20/5). Next, assess your daily energy needs, especially if your goal The results of the formula above are multiplied using the is weight loss. In the first week you should log every meal activity factor, which is based on the average daily activity: and foods eaten using a simple calorie counter (see • Lying down or sitting for the whole day x 1.2 examples of counters in the additional information page). • Sedentary work, no exercise x 1.3 • Sedentary work, light exercise x 1.4 • Light physical work, no exercise x 1.5 • Light physical work, light exercise x 1.6 • Light physical work, heavy exercise x 1.7

19 • Heavy physical work or heavy exercise x 1.8 hydrates, unless you consume alcohol. It is important • Very heavy physical work (logger etc.) or heavy sports to consider the energy acquired from alcohol if you (several hours per day) x 2.0–2.4 consume wine etc. It is also worth remembering that alcohol consumption disrupts ketosis and stops the use Many activity meters also estimate calorie expenditure of fat for energy until the alcohol has been burned off. based on the basal metabolic rate and daily activity. Of course, these are always rough estimations, but they may Estimating carbohydrate intake: give an idea of basic energy expenditure. • Generally, the goal in the initial phase is less than 20 g of net carbohydrates (not counting fiber) per day. After Estimating fat requirements: keto-adaptation, the goal is less than 50 g per day (with • 0.7–0.8 (i.e. 70–80 % of energy coming from fat) x total exceptions such as athletes) energy requirement/expenditure per day • 0.05 (i.e. 5% of energy coming from carbohydrates) x • For example, if your calorie requirement is 2000 kcal per total energy requirement/expenditure per day day, 1400–1600 kcal of that would come from fat • For example, if your calorie requirement is 2000 kcal per • In grams (one gram of fat equals 9 kcal of energy) this day, 100 kcal of that would come from carbohydrates means 1400–1600 / 9 = 156–178 g • In grams (one gram of carbohydrates equals 4 kcal of energy) this means 100 / 4 = 25 g Estimating protein requirements: • 0.15–0.25 (i.e. 15–25 % of energy coming from protein) x Of course, these figures vary from person to person. total energy requirement/expenditure per day For example, for athletes with a daily energy intake of • For example, if your calorie requirement is 2000 kcal per 4000–5000 kcal, the amount of absolute carbohydrates is day, 300–500 kcal of that would come from protein increased somewhat while usually remaining well under • In grams (one gram of protein equals 4 kcal of energy) 100 grams per day. this means 300–500 / 4 = 75–125 g The rest of the energy needs are covered by carbo-

20 KETOGENIC FOOD PLATE MODEL BUILDING A NUTRITIOUS AND HIGH-QUALITY KETOGENIC DIET

The ketogenic diet is naturally high in fat (see above), Water or tea which emphasizes fat quality as a crucial element when building the diet. If you are used to a diet high in carbohydrates, replacing them with fat may seem PROTEIN challenging at first. In practice, however, this is the Game, grass-fed step that makes building a ketogenic diet easy. The meat, poultry, fish and other seafood, eggs, VEGETABLES ketogenic plate model may also be helpful here (see plant-based Wide variety of image). A good approach is to select a (fat rich) starch-free vegetables, FATS vegetables with high source of protein to fill approximately one-third of Cold-pressed fiber content and oils, avocado, low-starch root the plate while the rest of the surface area is reserved seeds, nuts, vegetables animal fat for starch-free vegetables and oils of your choice.

Some follow the ketogenic diet by staring blankly at the percentages while forgetting about the quality of food. This type of ketogenic diet is called “dirty keto” as opposed to “clean keto” (consuming clean foods). We do not recommend dirty keto to anyone even GENERAL GUIDELINES: though it may work in terms of burning fat. • Choose locally produced and/or organic foods • Favor whole foods; avoid processed foods • If eating carbohydrates from time to time, have them in connection with exercise or in the evening

Source: Adapted from Presicion Nutrition (2018).

21 • Aged (raw) cheeses made from A2 milk (such as parmesan, manchego and goat cheese) • Raw and high-quality dark chocolate • Grass-fed meat / organic meat / game HEALTHY SOURCES OF FAT • Wild fish (fatty fish such as salmon and whitefish), clean Ideally, an individual should consume 1/3 of saturated fatty farmed fish (such as Arctic char) acids, more than 1/3 monounsaturated fatty acids and less • Organic eggs than 1/3 polyunsaturated fatty acids. • Organic cold-pressed cocoa butter

Saturated fatty acids are an important part of human The health benefits ofmonounsaturated fatty acids have energy supply, i.e. they act as fuel. On the other hand, been studied extensively. Research findings suggest a humans can produce saturated fatty acids from other fatty consensus regarding their health-promoting effects. acids; therefore, they are not absolutely essential. Another, Practically everyone seems to agree that cold-pressed even more important role of saturated fatty acids is to act virgin olive oil containing plentiful oleic acid (approx. as a crucial structural part of all cell membranes.52 80 %) is a healthy choice for a fat. A comprehensive 2014 meta-analysis found that increasing the intake of mono- High-quality sources of saturated fatty acids: unsaturated fatty acids in relation to saturated fatty acids • Organic butter (grass-fed if possible) reduced the risk of cardiovascular events by 9 %, stroke by • Organic ghee (clarified butter; made using the traditional 17 %, overall mortality by 11 %, and cardiovascular disease method) mortality by 12 %. These changes were found only in • Organic virgin coconut oil and red palm oil connection with olive oil use.53

22 High-quality sources of monounsaturated fatty acids: carbon double bonds) and elongation (adding two carbon • Cold-pressed virgin olive oil atoms). However, the conversion is not very efficient. Due • Cold-pressed macadamia oil to this, EPA and DHA are called conditionally-essential • Cold-pressed avocado oil nutrients. This means that in certain situations such as • Avocado under stress, when aging, during illness, etc. these • Olives nutrients are essential to the body and must be derived • Macadamia nuts from food.54 • Cold-pressed sea buckthorn oil • Sea buckhorn berries High-quality sources of polyunsaturated fatty acids: • Organic cold-pressed cocoa butter • Fatty fish, crustaceans, roe • Organic nuts (cashew nuts, Brazil nuts, almonds, pecan • Fish oil and fish liver oils nuts, hazelnuts, pistachios) • Cold-pressed hemp seed oil • Cold-pressed almond oil • Chia seeds • Organic almond paste/almond butter • Egg yolk (arachidonic acid) • Cashew paste/cashew butter • Fatty grass-fed meat / organic meat • Organic nuts (cashew nuts, Brazil nuts, almonds, pecan In terms of nutrition, polyunsaturated fatty acids can be nuts, hazelnuts, pistachios) roughly divided into omega-3 fatty acids and omega-6 fatty acids. The “originating fatty acid” of omega-6 fatty Fatty acids with 6–12 carbon atoms are called medium- acids is linoleic acid (LA), whereas for omega-3 fatty acids chain fatty acids. Based on double bonds of carbon it is alpha-linolenic acid (ALA). Both are nutritionally essen- chains, or rather the lack thereof, they are classified as tial fatty acids, i.e. the body is not capable of synthesizing saturated fatty acids. Medium-chain fatty acids (MCFA) / them from other fatty acids. The body can synthesize other medium-chain triglycerides (MCT) are naturally present long-chain omega-3 and omega-6 fatty acids from these in coconut oil and to some degree in fatty dairy products essential fatty acids via desaturation (creating carbon/ (10–20 %). Compared to long-chain fatty acids, medium-

23 chain fatty acids are very rapidly used for energy due to The benefits of medium-chain fatty acids in the diet being readily absorbed. Medium-chain fatty acids also may include: rapidly move to mitochondria, which make them an • Easier weight management and the activation of fat immediate energy source. Medium-chain fatty acids metabolism56 57 function best in the body in connection with a low-carbo- • Increased energy levels58 hydrate or ketogenic diet.55 • Balancing blood sugar levels and the prevention of metabolic syndrome59 These fatty acids have gained popularity as fatty coffee • Clearer thinking and brain function (especially in relation to has become more commonplace. Many people have caprylic acid which penetrates the blood-brain barrier)60 61 discovered the energizing effect of MCT oils in everyday • Improved digestion and intestinal microbiome, especially life. MCT oils are also used to support the ketogenic diet in obese individuals62 and to facilitate the onset of deeper ketosis. However, • Preventing bacterial and viral infections (lauric acid in medium-chain fatty acids should not be used to replace coconut oil)63 64 the intake of other essential and beneficial fatty acids. High-quality sources of medium-chain fatty acids: • Caprylic oil/caprylic acid • MCT oil • Cold-pressed coconut oil • Red palm oil

24 High-quality sources of protein: • Game (such as reindeer, deer and elk) • Wild fish and ethically farmed fish • Crustaceans and molluscs HEALTHY SOURCES OF PROTEIN • Grass-fed meat and organic meat (such as lamb, veal, Everyone is free to choose protein sources according to bison, ancient cattle breeds and wild boar) their preferences, whether entirely animal-based, vegan, • Offal (such as liver, heart and kidneys) or something in between. While refraining from • Organic eggs commenting on the ideologies of various diets, below • Organic poultry (such as turkey, chicken, goose and duck) are listed the highest quality protein sources that are • Fermented original soy products (such as natto and suitable for the ketogenic diet. tempeh) • Correctly treated lentils, beans and peas (soaking, Protein intake is crucial when building an optimal (keto- cooking, germinating, etc.) genic) diet due to the amino acids contained in it. Amino – These contain a fair amount of carbohydrates so acids contain four elements essential to life: carbon (C), should be used in moderation hydrogen (H), oxygen (O), and nitrogen (N). There are • Plant-based protein powders (such as organic rice, pea, approximately 500 amino acids, 240 of which are present in oat and hemp) nature. They are known as the building blocks of life, and • Full fat aged cheeses (such as parmesan, goat cheese for a good reason. There are 20 known amino acids that and sheep milk cheese) are crucial for humans, of which 9 are essential (must be derived from food) and the remaining 11 can be synthe- Favor fattier animal parts with connective tissue and sized in the body. These 20 amino acids are proteinogenic, bones. This adds fatty acids in addition to protein, as well i.e. they are used to produce proteins crucial for the as a wider variety of amino acids (such as glycine and body.65 proline) from connective tissue.

25 HEALTHY LOW-CARBOHYDRATE VEGETABLES LOW-STARCH VEGETABLES AND OTHER RELATIVELY Like olive oil, practically everyone regardless of ideology LOW-CARBOHYDRATE FOODS agrees that vegetables are universally healthy for all Once the ketogenic diet is off to a good start and the fat-/ people. Below are listed recommended low-carbohydrate keto-adaptation is progressing nicely, you can strategically vegetables that should be consumed liberally in the add foods containing some starch into the diet without ketogenic diet. disrupting ketosis in the long term.

• All leafy green vegetables (the darker the color the richer • Artichoke, carrot, beetroot, swede, parsnip, okra, sweet in nutrients) peas • Rucola, wild herbs such as nettle and dandelion, spinach, • Chickpeas, lentils, hummus, beans, fermented soybean kale, romaine and other dark green lettuces, chard, • Nuts and seeds endive and pak choi • Berries (lingonberries, bilberries and other tart berries) • Various herbs such as parsley, basil and thyme and low-sugar fruits (olives, lime, lemon, kiwi fruit, • Cabbages (such as red cabbage, cauliflower, broccoli, grapefruit) and Brussels sprout) as well as sauerkraut and other • Only use once keto-adaptation is clearly underway fermented vegetables • Fennel, celery, cucumber, zucchini, chives, leek Also use a wide variety of spices that help regulate blood • Sweet peppers, champignons, germinated beans, sugar and reduce silent inflammation in the body. These asparagus, bamboo shoots, tomato, green beans, include dried herbs, wild plants, wild herbs, black pepper, radish, watercress, water chestnut and sugar snap peas ginger, turmeric, various other peppers, apple cider (these contain more carbohydrates than other vinegar, garlic, cinnamon, cardamom, caraway and bay vegetables but are still quite low-carb) leaf.

26 DRINKS COMPATIBLE WITH THE KETOGENIC DIET KETOGENIC SNACKS Categorically, all low-calorie, sugar- and sweetener-free Snacks are by no means necessary for those on the keto- drinks are good and compatible with the ketogenic diet. genic diet – in fact, often the need for snacks is eliminated Fatty coffee does contain plenty of calories, but it is often as the regulation of blood sugar is balanced when in ketosis. used to replace breakfast and/or lunch. Below are listed some snack options compatible with the ketogenic diet: • Spring water • Mineral water • Avocado + a pinch of salt and a squeeze of lemon • Purified and filtered tap water (in places where tap water • If you want to add protein, eat a can of sardines in olive oil can be used for drinking) • A handful of nuts (for example macadamia, cashew, • Black coffee (try chaga coffee) walnut, pecan) and one square of dark chocolate (80 % • Various types of tea (green, white, pu-erh, black, oolong) minimum) • Bone broth • A couple of boiled eggs (leave the yolks slightly runny) • Green juices (homemade or from powder) and a pinch of high-quality salt • Lemon water (water with a squeeze of lemon) – The number of eggs depends on your energy needs • Apple cider vinegar soda (a refreshing drink that contains and hunger 1 tbsp apple cider vinegar, a pinch of salt and soda water) • Dried meat and a small punnet of bilberries • A small handful of olives and a couple of nuts If you consume alcohol, only have one drink and favor • Seed crackers with a touch of organic butter sugar-free drinks. A glass of wine every once in awhile is • Keto smoothie (a source of fat, protein powder, some not detrimental to the diet, but do favor dry, low-sugar berries) wines. • Protein drink made from almond milk or coconut milk (one scoop of whey protein mixed with fat-rich liquid) 27 X

TO MAINTAIN KETOSIS, AVOID THE FOLLOWING FOODS • All sugar (including bleached sugar but also other • All processed foods (usually high in carbohydrates and sugars, syrups, etc.); also honey, particularly in the initial other unfavorable ingredients) phase • Ready-made meals • As for sweeteners, true stevia is OK – other artificial • Various bars (almost always high in sugars) and meal sweeteners (such as sucralose, acesulfame K and replacement products aspartame) usually cause blood sugar swings, even • Potato chips and other snacks insulin secretion and obesity66 • Most fruits (in particular bananas, mangoes, apples, and • All cereal products (including gluten-free grains and other very sweet fruits) pseudo grains) • Dried fruits are extremely high in sugar • All other foods high in starch (such as potato, sweet • Sugar-rich drinks, juices and creamers potato and rice) • Milk

28 EXOGENOUS KETONES Exogenous ketones are likely to have effects similar to – NECESSARY OR GEEKERY? those of ketosis and beta-hydroxybutyrate (BHB) in alleviating inflammation.69 70 According to one case study, As their name implies, exogenous ketones are ketone exogenous ketones may alleviate the inflammation linked bodies (usually beta-hydroxybutyrate, BHB) that are used to Crohn’s disease.71 externally. Conversely, endogenous ketone bodies or ketones are ketone bodies produced by the body itself However, exogenous ketones do not function efficiently in once in ketosis. Thus, exogenous ketones are not in them- the body, i.e. they cannot be used efficiently as an energy selves ketogenic (producing ketone bodies), indeed, they source if the body is not keto-adapted (see above).72 may even inhibit it. This also means that the liberal use of On the other hand, the use of exogenous ketones may bodies prevents the burning of body facilitate the onset of ketosis when starting out with the fat for energy.67 ketogenic diet. They may also alleviate the symptoms of the “keto flu”.73 However, the use of exogenous ketones In the past few years a number of exogenous ketones have calls for moderation, as they have also been found to slow appeared on the market. There is currently little scientific down and inhibit ketogenesis (the production of ketone research on the effects of them on the body. However, bodies). This is natural – if a high volume of ketone bodies more research is conducted all the time. Exogenous appears from the outside, it makes no sense to keep ketones have been found to significantly increase ketone producing ketone bodies internally.74 body levels in the blood (BHB); in other words they mimic ketosis without endogenous ketone body production. The use of exogenous ketone bodies has been found to This has also opened the door for their use for various reduce appetite in connection with fasting.75 Consuming therapeutic purposes, for example, in the treatment of exogenous ketones is not beneficial with a meal. The epilepsy, Parkinson’s disease, and Alzheimer’s disease.68 most significant benefit of exogenous ketones becomes

29 apparent when food is not consumed but a significant Exogenous ketones take two predominant chemical energy boost is desired prior to exercise (in keto-adapted forms: individuals). However, current scientific studies are unclear on whether the use of exogenous ketones significantly • Ketone esters improves performance or not.76 – These are liquid esterified ketone bodies, used for example in connection with sports to improve Exogenous ketones may cause mild side effects (GI performance. Ketone esters are used particularly in symptoms, etc.) and are on average quite unpleasant studies79 – the market of consumer goods in this regard tasting. They are also generally very expensive and are is quite small. recommended to be used up to three times per day to maintain continuous ketosis. In summary, exogenous • Ketone salts ketones may be useful in connection with fasting to boost – These are ketones bound chemically to a salt cognitive performance and in some cases to improve (potassium, calcium or magnesium) and quite easy to exercise performance.77 78 use in powder form. Many different types of ketone salts exist on the market and they have also been widely studied.

MCT fatty acids can also be considered indirect exogenous ketone bodies, as they are rapidly turned into ketone bodies in the liver. MCT fatty acids increase the production of ketone bodies in direct proportion to the dosage.80

30 BOOSTING KETOSIS WITH INTERMITTENT FASTING

Intermittent fasting means fasting for a significant portion of the day (for example 16 hours) and consuming the daily food intake during the remaining eating window (for example 8 hours). The simplest way to implement this is to extend the overnight fast by skipping breakfast81 and enjoying the first meal of the day in the afternoon.

The concept of intermittent fasting came about to counter the trend of “six small meals a day” promoted by the food industry and fitness culture of today. Grazing is often rationalized using claims of activating the metabolism and making weight management easier. However, no scientific basis has been found for such claims.82 83 In fact, the basal metabolic rate (BMR) increases slightly after a 36-hour fast – it is only after 72 hours that the BMR begins to slightly decrease.84

Intermittent fasting is helpful in achieving the desired calorie restriction85 if the goal is removing waste products from the body (autophagy) or weight loss. Improvements in the regulation of sugar metabolism have also been detected in conjunction with intermittent fasting.86

31 From the perspective of evolution, human beings evolved • Fasting for 16 hours followed by an 8-hour eating to eat when there is food available (usually in the evening) window (”Leangains”) – the rest of the time was spent on acquiring the food • Fasting for 18 hours (fatty coffee is allowed) followed (in the morning and during the day). Intermittent fasting by a 6-hour eating window (”Bulletproof Intermittent works well in practice, as it allows for the consumption of Fasting”) satisfying meals during the eating window while maintaining a moderate energy intake overall. Intermittent fasting (or Health benefits of fasting/intermittent fasting:87 fasting in general) is not generally recommended for • May extend lifespan by slowing down the aging process individuals who are under 18 years of age, pregnant, • May reduce the risk of developing metabolic and chronic breastfeeding, severely fatigued, or suffering from diseases such as: chronic fatigue syndrome. – Cancer – Diabetes During fasting, water, tea, coffee, and mineral water are – often consumed to maintain fluid balance. – Arthritis – Neurodegenerative diseases (such as Alzheimer’s There are various methods of intermittent fasting: disease) • Fasting for 24 hours 1–2 times per week (”Eat Stop Eat”) • May improve insulin sensitivity and lower blood pressure • Fasting for 20 hours followed by a 4-hour eating window • May reduce oxidative stress in the body (”The Warrior Diet”) • May improve the hormonal balance of the body • Fasting for 36 hours followed by a 12-hour eating window (”The Alternate Day Fast”)

32 RECIPE

BREAKFAST / KETO OMELET Select the number of eggs based on your energy needs. • 2–5 organic eggs Combine the eggs and a splash of water in a bowl, whisk until • 1 tbsp water the eggs are well mixed. • 1 tsp lemon juice • 80 g spinach Dice the red onion and tomato and brown them in ghee or olive • 1 tomato oil in a hot frying pan for about a minute. Add the spinach. Cook • 1/3 red onion until the spinach has wilted. Add to the bowl with the eggs, then • 1 tbsp crushed nettle add crumbled feta cheese, nettle and spices. Mix until well • 50 g (organic) feta cheese combined. Cook on medium heat until almost set, then fold over. (made from sheep’s and goat’s milk) • black pepper, sea salt, dried paprika Tap the cooked omelet for a moment, then transfer onto and thyme, to taste a plate. Garnish with fresh parsley. Serve • 1 tbsp ghee or olive oil the omelet with fresh cucumber and • 1 tsp fresh parsley broccoli sprouts.

33 SUMMARY

Ketosis is a natural metabolic state activated by fasting, heavy calorie restriction, or significant carbohydrate restriction. Throughout evolution, ketosis developed as an alternative system to glucose metabolism. It has been active particularly in times when the amount of food available has been inadequate.

The ketogenic diet is gaining more and more understanding, indicated by the huge amount of new research as well as the exponential growth in the number of people adhering to the diet. Studies have found the ketogenic diet and ketosis to be the most effective method for weight loss, balancing blood sugar swings, boosting overall energy levels, and intensifying the burning of fat for energy in the body.

The ketogenic diet is generally simple to build and easy to adhere to after potential initial challenges (such as the keto flu). Activating the ketone body production increases metabolic flexibility in the body, which means that the body learns to efficiently use both glucose and fat as energy sources.

34 Sources

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