Troubleshooting Guide Part I: “In Ketosis, but I Don’t Feel Well…”

Welcome to Keto Sister.  If you have been following my Keto Basics series, then you already have insights into being in ketosis and understand:

• the benefits of eating a ketogenic (keto) diet.
• how the body is fueled and why we do not actually need carbohydrates (carbs).
• how to eat to get into nutritional ketosis.
• how to make delicious meals, including some of my favorite recipes.

If you missed any of this, I strongly suggest you start at the beginning.  The series is written as an introductory guide to those who are new to keto eating.

Now that you are in ketosis, how is it going?  If you have implemented your protocol well, then you should feel warm, energetic, and calm and balanced.  The body—the brain in particular—likes to run on ketones and when I hit my stride (so to speak), I felt fantastic.

Yet what I hear most often from those new to ketosis is: “I reduced my carbs and I’m pretty sure that I am in ketosis, but I don’t feel well.  What am I doing wrong?”  This is a common complaint and there are many possible solutions.

Getting into ketosis is easy.  It only requires that carbs be limited to low enough levels to encourage the body to replace glucose as fuel with ketone bodies.  However, following a well formulated ketogenic protocol (as termed by Drs. Volek and Phinney, authors of The Art and Science of Low Carbohydrate Living) is more complicated than simply eliminating carbs from your diet.  Once you have eliminated sugar and sweeteners, grains, legumes, starches and most fruits and are eating your fill of fatty (not lean) meats like ground beef, steak, lamb, pork chops, ribs, fish and seafood, as well as eggs, leafy green vegetables, crucifers like broccoli and cauliflower, cabbage, kale, green beans, mushrooms, and fruits like cucumbers, bell peppers, tomatoes, and even sweet fruits like strawberries and blueberries, there are a few additional details that make adapting to ketosis easier.

Troubleshooting Part I: What You May, In Fact, Be Doing Wrong 

Below is the first of a two-part troubleshooting guide of the most common problems people can develop when new to ketosis and strategies for resolving them.  A few simple tweaks are all that are needed in most cases to take people from feeling terrible to feeling incredible.

1. “I have headaches, brain fog and my energy is low.” Are you salting your foods?  The recommended daily allowance (RDA) in the U.S. is 2.3 grams of sodium, which is about half a teaspoon (see https://health.gov/dietaryguidelines/2015/guidelines/appendix-7/ for details but ignore the macronutrients, which I explain in a footnote below).  However, some scientists in Canada found that sodium intake needed to be higher to minimize risk of poor health outcomes (see graph titled “Rethinking Sodium Guidelines”).
   Low carbers need to consume more salt than those who eat a high carb diet because ketosis encourages the body to release water at a faster rate.  Carbs help the body to retain water (get it? carbo-HYDRATES).  When you reduce carbs in your diet to ketogenic levels, sodium can help the body to stay hydrated in the absence of carbs because sodium also helps you to retain fluid. Also, because fluids and the sodium are released from the body at a faster rate when eating low carb, sodium needs to be consumed each day.  Adding 5 grams or one teaspoon of sea salt or Himalayan rock salt to your keto diet should help eliminate these symptoms.  This may sound like a lot, but the graph shows consuming sodium at the levels the government recommends (1/2 teaspoon) is associated with increased risk of death whereas consuming one teaspoon of salt is associated with the lowest risk.

2. “My heart sometimes races or feels funny since I lowered my carbs.” You may need more potassium.  The RDA for potassium is 4,700 mg.  Potassium is abundant in many higher starch sources such as potatoes (512 mg per cup), bananas (400 mg), and legumes (250-500 mg per ½ cup), but it is also abundant in low carb foods as well.  Be sure to regularly eat foods like avocado (1,068 mg each), spinach (839 mg per cup), and acorn squash (450 mg per ½ cup) (USDA Food Composition Databases, 2017).  In addition, a potassium supplement can be helpful.
3. “I have leg cramps.” The missing electrolyte in this case is magnesium.  The RDA for magnesium is 310-400 mg, but I find this estimate to be low for some of my clients.  Magnesium is the most abundant mineral in the body and is an essential component in over 300 various functions (IOM, 1997; Rude, 2010; Rude, 2012).  It is in both animal and plant foods, and is abundant in green leafy vegetables, nuts and seeds, avocado, chicken, salmon and beef (Office of Dietary Supplements, 2017).
4. “I salt my food, but I still have terrible headaches and also feel tired, dizzy, and my sinuses are congested.” These are symptoms of histamine and salicylate intolerance.  If you are salting your food and know you are eating enough calories rather than severely restricting them, then the foods you are eating may be triggering this reaction.  According to Hanuskova & Plevkova (2013), those with histamine intolerance (HIT) develop a histamine response to aged foods and those with naturally high amounts of histamine, including:
   • Aged foods like bacon, salami, lunch meats and canned meats.
   • Aged cheeses and fermented dairy (yogurt, kefir, sour cream).
   • Fermented vegetables (sauerkraut, pickles, olives).
   • Fermented liquids (vinegars, wines, soy sauce).
   • Chocolate and teas (black, green, mate).
   • Some fruit and vegetables (avocados, spinach, tomatoes, eggplant, citrus, etc.).
   • This is because foods grow histamines as they age, so food that you made yesterday and reheat today for lunch is higher in histamines the next day than when it was cooked fresh.

   Is eating keto now impossible for you?  No, it was not for me.  What can you do to resolve this?  Here’s what worked for me:

   • Avoid the foods above temporarily.  If the foods that bother you are your primary sources of potassium, be sure to substitute with other potassium rich foods or take a supplement if necessary.
   • Prepare your meals fresh and freeze leftovers. Histamines develop more slowly on frozen foods.
   • Consider taking natural anti-histamines, such as vitamin C and quercetin, with meals.
   • You may have a diamine oxidase (DAO) deficiency, in which case you can buy supplements that assist with breaking down histamine.
   • HEAL YOUR LEAKY GUT. This turned out to be the cause of my HIT and is the cause is most cases.  Avoid the foods that cause leaky gut (grains, dairy, legumes) and enjoy foods that heal the gut like bone broth, collagen and gelatin.   Supplements like l-glutamine can also help heal the cut lining.

   Dr. Myers has some great information about causes of and treatments for HIT: http://www.amymyersmd.com/2016/02/everything-you-need-to-know-about-histamine-intolerance/.

5. “Every time I eat, I have heartburn/indigestion/acid reflux” or “I can’t seem to handle all the fat.” Developing the enzymatic processes to digest all of the fatty foods eaten on a ketogenic protocol takes some time.  If your previous diet was high carb/low fat diet, then adjusting will be even tougher on your digestive system.  Your body in time will adjust, but when first starting out you may need some additional support.  What helps the body to digest fats?
   • Betaine hydrochloric acid (or betaine HCL) can be taken in pill form to increase stomach acid, which helps the body to break down fats and proteins. Despite recommendations to take stomach acid reducers, indigestion is a sign of low stomach acid.  Be careful with betaine HCL, however, as it is very powerful and can upset the stomach when taken in high amounts.
   • Apple cider vinegar (raw and unpasteurized) helps increase stomach acid and is much safer on the body than betaine HCL. Mix 1 tablespoon of apple cider vinegar into a few ounces of water and drink this 10 minutes before meals.
   • Taking a digestive enzyme with meals is a great temporary solution.  If you find yourself unable to move beyond taking enzymes with every meal, then you may have digestive issues that require further treatment (such as a leaky gut, gallbladder insufficiency, etc.  I will discuss these in detail in an upcoming post.).
   • Probiotics and eating fermented foods like sauerkraut and pickles (homemade, not store bought) can increase the gut bugs that help us digest our foods.

I hope the information above helps those of you who are struggling with your keto adaptation to feel better quickly.  Next week, I will review five additional common complains and solutions, including why you are not losing weight, why your weight loss has stalled, why you are cold/losing your hair/ not sleeping well/lost your menstrual cycle (ladies), and more.  If you have any questions, are struggling with a complaint that was not covered in this week’s post or want a personalized keto protocol created just for you, then I invite you to complete the Lifestyle Questionnaire or contact me at airia@ketosister.com. Thanks again for reading.

Note: The 2015-2020 Dietary Guidelines contain inconsistencies that are worth addressing.  For example, it is recommended that an adult woman eat approximately 1,800 calories.  However, this is how the grams as written break down:

Carbohydrates             130 grams or 520 calories
Protein                            46 grams or 184 calories
Fat                                   No grams are specified

Additionally, the guidelines also state that carbohydrates should comprise 45-65% calories, protein should equal 10-30% and fat should equal 25-35%.  Based on the 1,800 calories the table recommends:

Carbs should total 202.5-247.5 grams or 810-990 calories.  The table underestimates carbs.
Protein should total 45-135 grams or 180-540 calories.  The table underestimates protein.
Fat should total 50-70 grams or 450-630 calories.

My point?  How can the American public trust these guidelines when the authors themselves seem confused when they were written?  There are better ways to estimate macronutrients.  Refer to my guidelines for how to eat in my Keto Basics series to get started.

References

Hanuskova E. and Plevkova J. (2013) Histamine Intolerance.  Cesk Fysiol, 62 (1): 26-33.

Institute of Medicine (IOM) (1997). Food and Nutrition Board. Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Washington, DC: National Academy Press, 1997.

Office of Dietary Sciences, National Institutes of Health (2017). Magnesium: Fact Sheet for Health Professionals.  https://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/.

Rude RK. (2010) Magnesium. In: Coates PM, Betz JM, Blackman MR, Cragg GM, Levine M, Moss J, White JD, eds. Encyclopedia of Dietary Supplements. 2nd ed. New York, NY: Informa Healthcare: 527-537.

Rude RK. (2012) Magnesium. In: Ross AC, Caballero B, Cousins RJ, Tucker KL, Ziegler TR, eds. Modern Nutrition in Health and Disease. 11th ed. Baltimore, Mass: Lippincott Williams & Wilkins: 159-175.

U.S. Department of Agriculture, Agricultural Research Service, Nutrient Data Laboratory. USDA National Nutrient Database for Standard Reference, Release 28. Version Current:  September 2015.  Food Composition Databases: https://ndb.nal.usda.gov/ndb/.

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/appendix-7/