Fahim Tazwar, MD MPH:
Diet can be confusing. Recommendations are ever changing. Until recently, refined carb was favored over fat. However, with obesity, ever growing diabetes, worsening hypertension and many other diseases, nowadays, refined/processed carb is falling out of favor and focus is shifting toward healthy fat & pro-tein rich food. One such diet is the Ketogenic diet which is gaining popularity. With the blessing of social media, dieticians and physicians are being vocal about the benefits of ketogenic diet (in short, Keto diet) and how it can be the answer of many chronic dis-eases. Here, I will answer some specific questions regarding this diet.
(1) Does Dr. Jahangir Kabir promote Keto diet?
What I understood from his video and Facebook posting, his suggested diet is the Bangladeshi version of Keto diet. He simplified and made it easy for Bengali speaking people to understand and follow the diet plan. Similar diet is discussed in detail on YouTube by renowned weight loss expert, Eric Berg DC since 2008 who also has 3.4 million followers on Youtube.
(2) What is Keto Diet?
It involves drastically reducing carbohydrate intake and re-placing it with fat. It’s a high fat diet. The reduction in carbs puts your body into a metabolic state called ‘ketosis’ where body breaks down fat to ketone bodies. Main idea in Keto diet is to keep carb below <20g to force body to look at fat and protein for energy. So whenever body need energy, in-stead of making you hungry, it will simply start breaking down storage fat.
(3) What are the benefits of keto diet?
Keto diet can help in the treat-ment of Obesity (excessive weight), Type 2 diabetes, PCOS, Irritable bowel syndrome, Fatty liver, GERD (Heartburn), and Metabolic syndrome. It has the potential to be helpful in Alzheimer’s disease, skin disease such as eczema/psoriasis, allergies, Cancer, Type 1 & gestational (during pregnancy) diabetes and possibly in Asthma also. Keto diet can help improve physical performance, boost energy, clear mind and feel better.
(4) Do I need to talk to my physician before starting Keto diet?
Please discuss with your primary care about keto diet before starting if you have any medical conditions, especially kidney dis-ease, kidney stone, Gout, sodium problem, diabetes (as medicine need to be adjusted), any type of heart disease (including stent or bypass surgery), family history of heart disease, eating disorder such as bulimia/anorexia, history of hepatitis, preexisting liver dis-ease (not fatty liver), pancreatic disease (ex: pancreatitis), history of gallstones or gallbladder dis-ease, currently pregnant/ breast-feeding mother or any other conditions where doctors have warned you about fasting or high fatty diet.
(5) Can you explain in detail how to start keto diet and maintain Ketosis?
There are 3 stages of keto diet. Let’s go step by step.
Stage 1 [Starting Ketosis] Day 1- 5 = Eat only high fat food (70%), mild amount of protein (20%) and the rest are vegetables. Look below to see what to eat and what to avoid. Absolutely NO sugary products including juice and soda. No rice, wheat, corn, potato product. No fruits either. No beans, lentils or grain of any product including oatmeals. Replace vegetable oil with coconut and extra virgin olive oil. Can use butter, ghee, cheese. Add plenty of fish and meat in the diet. Eat as much as vegetable you can eat (avoid anything that grow under the ground). Eat regularly cooked curry. Cook with less gravy and spice. Add fat from eggs, avocado, grill cheese. Can fry egg with butter. Whenever hungry, have peanuts and walnut. Can fry them with butter also. After 3rd day, Gluconeogenesis and protein breakdown kicks in. After 4th or 5th day, keto flu symptoms might appear with dizziness, headache, body ache. Add pinch of salt (sodium) in your glass of water and eat avocado (high in potassium) to prevent these symptoms.
Day 6 – week 2 = Start full fasting or intermittent fasting. Fasting is the best way to kick start ketosis and head toward keto adaptation. 3 days of fasting can get to ketosis quickly. During this time can drink water with salt or apple cider vinegar. However full fasting for 72hrs is hard to do. In-termittent fasting is slightly slower process. Avoid breakfast. Eat lunch around 12-1pm and diner at 5-6pm. No other meal or snack in between. This give 16-18hrs of intermittent fasting with water only. This fasting will de-plete the glucose storage (glyco-gen) in 12-16hrs and force the body to go into the fat reserves for fuel. Gluconeogenesis and protein breakdown slows down. Fasting also promote autophagy which help recycling old and damage part of the cell. It also helps clean-ing up damaging bacteria, fungus and toxin from the body.
Stage 2 [Keto adaptation]
After 2-3 weeks, body may start adapt to different fuel You will not be hungry anymore. You are not craving for carb anymore. Will not be irritated if you skip a meal. This means when energy is needed, instead of making you hungry and crave car- bohydrates, your body has now started to look at different source for fuel, your very own storage of fat. This is the phase you lose most weight. Now start incorpo- rating some physical activity. Don’t push for high intensity at the beginning. Go for aerobic ex- ercise such as walking, yoga for 30 mins with 4-5 days a week. Moderate intensity exercise is
ideal for maximizing fat burning. Exercise is better to do while in fasting mode. With low sugar in the body, fat will burn more and quicker, hence faster weight loss.
Keto Adaptation takes time. Sometime few weeks to even several months. Good news is that once your body is keto- adapted, your metabolism will not go back to old self easily. You can cheat with carb sometime. Some keto gurus even advice that once into keto adapted, you can add lit- tle carb (ex: brown rice, brown bread, pasta) to shift in and out of ketosis occasionally, maybe once a week. This fluctuation allows your metabolism to become stronger and more
Stage 3 [ Maintenance with metabolic flexibility]
This is when you master over your metabolism. In this stage, you can use both glucose and fat for fuel most effectively. This means, you are still follow- ing keto diet but not so strictly. You can also now add some fruits, beans, legumes to our regular But you can never go back to high carb diet that you were abusing before. Now focus on building di- verse gut microbiomes with more fiber and probiotic. You can add good fiber in the form of oatmeal and lentils. Can have some milk in your tea also.
What do I avoid in this diet?
- Avoid anything sweet. Trust your tongue. Anything that tastes sweet, avoid it. For exam- ple, honey, sugar, jaggary (ghur), sweet product (misti), candy, cake, coconut pita, dates (khejur) and even sweet fruits and vegeta- bles.
- Avoid soda and juice. As we know these drinks are infested with
- Avoid eating anything that comes from grains such as rice, wheat, and oatmeal. This in- cludes flour, roti/paratha, bread, pasta, noodles, cereal, pita, lachi/shemi, biscuits and These are carbohydrates that gets converted into sugar in the body.
- Avoid corn, yams and potatoes also. Potato and corn are high in carb. one medium size po- tato has 37g of carb and corn has 123g of carb. Artichokes has the highest amount of carb. Avoid them at all cost in keto diet. Gen- erally, avoid vegetables that grow under the
- Avoid milk and yogurt. They contain sugar. Fat free yo- gurts usually have high in sugar. 2% milk has 12g sugar perSafe to consume milk products are Cream (ex: whipping cream, cof- fee mate cream) as sugar is being removed from these products.
- Avoid all type of veg- etable oil such as Corn oil, Soy- bean oil, and canola oil. Replace with coconut oil, butter, extra-vir- gin olive oil
- Avoid fruits at the begin- ning of keto diet, because they are also high in Excep- tions are Avocado, raspberries/blackberries/strawber- ries, star fruits and lemon. Ex. 1 medium size apple has 25g of carb. In Keto diet, total daily carb intake should be no more than 20g, hence one apple can fail the keto diet. Once achieved desire weight, can reintroduce sour fruits as they are low in carbs.
- Avoid beans and peas in-
cluding lentils (dal), beet, chick- peas (chana), legumes at the beginning. Can add them later.
- Avoid adding any sugar in tea or coffee. Can add
- Avoid eating fast and Take time to chew food well. This helps in satiety and proper digestion.
- What can I eat then?
Following foods are suggested in keto diet.
- 20 – 40gram fat per meal with 2meals Ex: 4 egg (20g fat) or 4oz Beef (20g fat) in each meal. 1 tablespoon coconut oil or olive oil will add 14g of good fat also. 3-6oz of fish in each meal.
- Eat plenty of good fat such as extra virgin olive oil, co- conut oil, Peanut butter (organic with sea salt), Avocados (high in potassium, more than bananas), flaxseed oil, sesame
- Full Fat 100% grass fed cheese products such as cream cheese, mozzarella, cheddar, pep- per jack , Parmesan, Swiss Cheese has fat soluble vitamins (A, D, E, K).
- Other sources of fat in keto diet can come from 1 table- spoon heavy cream (5g fat), 1 ta- blespoon coconut oil or olive oil (14g) or 1 tablespoon Butter (10g fat)
- Any type of fish, prefer- ably wild caught and oily sea fish such as Sardine, Trout, Herring, Salmon. Have plenty of Shellfish, shrimp and crabs.
- Any type meat however mind the quality (not farm animal) and quantity as they are high in
- Non-starchy green veg- etables: leafy greens, cabbage, broccoli, cauliflower, peppers and onions. Usually any vegetables, chicken or beef curry that wemake. Don’t put potato, lentils, beans in the curry. Avoid carrot and sweet squash or any other produce that taste sweet.
- Nuts (badam) and Seeds: walnuts, pistachios, sunflower and pumpkin seeds, and almonds. They can be fried in a small amount of organic
- Don’t eat too much fat in the first 2-3 days of keto, other- wise it will overwhelm the gall- bladder, cause bloating
- How much Protein to eat in Keto diet
3-6oz of meat or fish or egg per meal. You can’t have >25% of calories from protein. Another way to calculate is 0.36 to 0.7g protein per pound (lbs) of your weight for the whole day. Ex 140lbs person would need mini- mum 50g and max 100g protein a day. If 2 meals per day, then 25- 50g per meal. An active person who is athlete, works long hours, may need higher end of 100g per day. Anything less would be bad because when fasting, you will lose muscle before fat start to burn. Anything more, will prevent fat burning as high protein can also bring out insulin. Make sure to calculate and find, how much protein you can eat based on your body weight and adjust based on weight and activity. Examples: 4 eggs (24g protein), 3oz chicken (28g protein), 3oz of beef (22g protein), 5oz lobster (26g protein). You eat to see how much it satis- fies you but don’t go beyond 8oz per day.
- Can you list all the special item I need to get for keto diet?
Always get organic foods and products such as organic pasteur- ized eggs, organic meat (from pas- ture-raised animal, not farm raised), organic unfiltered raw apple cider vinegar with mother, extra – virgin olive oil, organic cold pressed coconut oil, organic butter, organic ghee. For salt, many prefer Himalayan pink salt (has iron, potassium, magnesium and calcium).
Keto diet is known to medical society for close to 100yrs. Mayo clinic started prescribing keto diet for epilepsy since 1920s. Benefit of fasting is not new either. This type of diet and fasting can be beneficial for weight loss, dia- betes, epilepsy, may be HTN (after weight loss) and possibly IBS (due to low carb). However, it has to be done correctly and under supervision sometimes as this diet promote high fat, espe- cially saturated fat. It is highly de- bated topic currently whether saturated fat is safe or not. Med- ical pandits and nutritionist are di- vided on this. It is considered as unhealthy by Mayo clinic, Amer- ican Heart Association and many other medical boards. Until we have enough research to prove that high saturated fat is not harm- ful, we should be cautious. I would limit high fatty food from animal sources such as liver, eggs (>1 or 2 day), chitlins, cow feet (nehari), and lards. Rest of the diet plan, we can follow. Multivitamin supplement would be wise until 3rd stage of keto diet is achieved. I listed above who should speak to their doctors first before embark- ing on ketogenic diet. Remember it is a lifestyle change, not just a temporary measures for a few months. If you go back to your old diet of high carb, weight will come back and so may the diseases.