August 26, 2013


Ketones and Carbohydrates: Can they co-exist?

Can you "carb-load" and stay in ketosis?

Read Time 8 minutes

For reasons I’m still struggling to understand, the idea of “nutritional ketosis” (NK, to be distinguished from starvation ketosis, SK or diabetic ketoacidosis, DKA) is often discussed and debated in much the same way as religion or politics. Perhaps this can be said of all nutrition, which is a shame.  Nevertheless, in my continued defiance of such sensitive topics, I’d like to add another layer of complexity and nuance to this discussion.

The “rule of thumb” for NK is that caloric intake is determined as follows (this excludes a subset of ketogenic diets known as calorie-restricted KD which, as the name suggests, is specifically restricted in calories):

  1. Carbohydrate (total, not “net”): less than 50 gm/day, but ideally closer to 30 gm/day
  2. Protein: up to 1 to 1.5 gm/kg, but ideally below about 120 gm/day
  3. Fat: to satiety

Let me illustrate what this looks like for Joe (left), Jane (middle), and Jeff (right — an example of a calorie restricted KD), three hypothetical people in NK — but each with different caloric requirements.


As a general rule, as caloric requirement increases the proportion of calories derived from carbohydrate and protein decreases (and the contribution of dietary fat increases), even while absolute intake of carbohydrate and protein increases.

Anyone who has bought a blood ketone meter knows how tough it can be to get “into” ketosis by carbohydrate restriction (since everyone asks, I use the Abbott Precision Xtra meter which uses two different strips: one for glucose and one for beta-hydroxybutyrate, or BHB).  Most practitioners consider the minimum threshold of NK to be a fasting serum level of BHB above 0.5 mM.  I’m a bit more stringent in my practice and like to see fasting BHB levels above 1 mM.   To give you a sense of one person’s numbers (mine), over a 6-month stretch in 2013, when I was in NK, my mean (i.e., arithmetic average) morning fasting level was 1.7 mM with a median value of 1.4 mM.  The highest morning level during that period was 5.2 mM.  (The highest morning level I have ever measured in myself is 5.7 mM.)

But, it took me a long time to get it right, especially since at the outset of my foray into NK I was consuming between 4,000 and 4,400 kcal per day.  (My average daily caloric intake for weight stability was about 3,800 kcal per day, which was validated by doubly-labeled water.)  I could still easily “fall out” of NK.  For example, on my daughter’s 5th birthday she insisted I have some of her tikka masala (contains lots of sugar), naan bread, and mango ice cream.  How could I say no to a birthday girl who insisted on going to the nicest Indian restaurant in San Diego?  As to be expected, the next day my BHB was 0.2 mM, and it took me 2 days to get back above 1 mM.

Here’s a little secret I’m about to let everyone in on… I like carbohydrates. I love sushi (though I now mostly eat sashimi).  I love Indian and Thai food, though I prefer to make curry myself to keep sugar out.  I make (and eat) the best hummus this side of the Nile River. I’ve figured out how and when I can eat them to meet the following conditions:

  1. Stay in NK (except on a few occasions like my daughter’s birthday);
  2. Increase my anaerobic performance;
  3. Preserve most (but not all*) of the benefits I enjoyed when I was much more strict about my ketogenic diet.

How, you ask? By learning to calculate my glycogen deficit.

(*) For me, the leanest body composition I achieved as an adult was in strict NK with no attempts to do what I’m about to describe below.  Since I’m not a model and nobody cares if my body fat is 7% or 10%, I’m happy to be a little less lean if it gives me the flexibility to increase performance and live a slightly more sane life.  At least for now.

PLEASE NOTE: I have never suggested, and can’t imagine I ever will suggest, that a KD is “best” or “right” for everyone.  What I describe below may seem extreme, both in the amount of work required and the actual application.  I fully acknowledge that (1) this is a highly analytical approach to eating, and (2) that I’m a “freak” (my wife’s words, not mine). I certainly don’t do this often, unless a lot is on the line (e.g., a big ride), but I like having this technique in my armamentarium.

If you’ve watched my presentation from 2013 at the IHMC, then you’re familiar with RQ.  Through years of metabolic testing I have a pretty good sense of my RQ at any moment in time – when I’m sleeping, when I’m sitting around (most of the time), when I’m riding my bike at 200 watts, when I’m riding my bike at 400 watts, when I’m lifting weights, etc.  This allows me to calculate what proportion of my energy I derive from glycogen and what proportion I derive from fatty acid.  Consider the following example:

If I ride my bike at an average of 185 watts (you’ll need a power meter to infer this) for, say, 2 hours, I know my average RQ is between 0.76 and 0.80.

The approximate formula is %CHO = 3.333*RQ – 2.333, which can easily be derived from the observation that %CHO utilized increases linearly from 0% at RQ 0.7 to 100% at RQ 1.0.

Furthermore, I know my VO2 at 185 watts is 2.9 liters per min, which means (using the Weir formula which I presented previously) my energy requirement was about 14 kcal per minute, or 1,680 kcal over 2 hours.  Hence, of these 1,680 kcal needed to pedal 185 watts for 120 minutes, 336 to 554 kcal came from glycogen.  In other words, I utilized between 84 and 138 gm of glycogen.

(By comparison, several years prior to being in NK, this effort in me would have taken place at a slightly higher VO2 – closer to 3.2 liters per min – and at a much higher RQ – between 0.90 and 0.95 – meaning the exact same work output would have required somewhere between 300 and 400 gm of glycogen!  That’s a real state of metabolic inflexibility.  Basically, I was entirely dependent on carbohydrates for energy.)

Since the first metabolic priority for ingested carbohydrate is glycogen replenishment, I can, in this setting, consume probably somewhere between 60 and 120 gm of carbohydrate following this ride and stay in ketosis.  Why? Because those carbohydrates are prioritized to replenish my glycogen stores AND I am highly insulin sensitive.  Note the *AND* in this last sentence. (The especially astute reader will realize some of this glycogen debt will be replenished by protein and glycerol, the latter of which is liberated by lipolysis – see post on fat flux for a primer).

Clearly I didn’t consume this amount of carbohydrate on my daughter’s birthday, so why was I out of ketosis the next day? Because my glycogen debt was not high.  Of course, I knew this and didn’t really care.  But, if I know my wife wants to go out for sushi one night, and I know she’s going to make me eat a California roll, I can “rig it” such that I show up to dinner with a glycogen debt appropriate enough to enjoy them without significantly interfering with my liver’s BHB production.

Extreme example

At one point, I did two tough bike rides on consecutive days.  Each day we rode 110 miles under challenging conditions.  Over 6,000 feet of climbing each day and very strong winds, which were either headwinds or cross-winds.  On top of this, we rode pretty fast. For the purpose of illustration I recorded everything I did and ate on the second day, which I rode a bit easier than the first day.

The second ride took 6 hours and 5 minutes.  My average normalized power output was 225 watts, and arithmetic average power output was 184 watts.  Based on mechanical work output, this required about 5,000 kcal.  Factoring in the other 18 hours of that day, my total energy expenditure was about 6,800 kcal for the day, obviously not an average day. (A detailed explanation of where the extra 1,800 kcal were expended is beyond what I want to get into now, but it’s basically the energy required to keep me alive – transport ions, contract voluntary and involuntary muscles, etc. — plus move me around, and digest food).

So what did I eat that day?

  1. Breakfast (pre-ride): 5 scrambled eggs, 2 sausage links, 3 pieces of bacon, coffee with cream.
  2. In ride nutrition (I spread this out over 6 hours): 14 oz (not a typo) of salted cashews, 2 Quest bars, 1 peach, 1 apple, 6 bottles of Biosteel High Performance Sports Drink, water. (Since I know someone will ask, I did not consume super starch this day since I was craving cashews as my carbohydrate source and was craving more sodium, given the 90+ degree temperature.)
  3. Late lunch/early dinner (post-ride): 2 oz ham, 3 oz pulled pork, large salad with oil and vinegar dressing, 2 slices of cheddar cheese, 6 mini hamburger patties, 2 tomatoes.

What did this amount to?

  • Fat – 351 gm, or 3,160 kcal of fat
  • Protein – 245 gm, or 980 kcal of protein
  • Carbohydrate – 321 gm, or 1,284 kcal of carbohydrate

(I used package information and Nutritionist Pro software to calculate this.)

Hence, on this day I consumed about 5,400 kcal in total at the following ratio:

  • Fat – 58%
  • Protein – 18%
  • Carbohydrate – 24%

By all conventional wisdom I should not have been in ketosis the next morning, right?

The following morning, my BHB level was 2.2 mM and blood glucose was 5.1 mM.

Teaching point I can’t resist: Following 2 days of significant caloric deficit, about 3,000 kcal in total, I should have in theory lost about a pound (mostly fat, possibly some muscle) which would have been noticed on a scale.  Instead, I gained 8 pounds over those 2 days! Sure it was mostly water retention, both from the glycogen (small) and the fluid accumulating in the interstitial space (“thirds space” fluid losses, large) due to a systemic inflammatory response.  This happens under extreme conditions of exercise.  In fact, the harder I exercise, the more weight I gain, transiently.  I am at my absolute lightest following 2 days of travel (i.e., rest).  So before freaking out at the sight of the scale, keep in mind that most day-to-day weight movement in our bodies is indeed water movement into and out of the plasma and interstitial space, respectively.

What’s my point?

Context matters!  If I ate even one-quarter of that amount of carbohydrate and two-thirds of that protein on a normal day – say, 2.5 hours of riding or 1.5 hour of riding followed by 1 hour of swimming, or a day of travel with no exercise – I would have been out of ketosis for two days or more. (Of course, my appetite on those days would not have allowed me to eat 5,400 kcal without feeling sick, but I won’t get into that until a later post.) But on this day, with these glycogen demands, I was able to maintain the perks of ketosis AND glycolysis simultaneously.

There are days, though, when I overshot my glycogen need and end up with a low BHB and high fasting glucose the following morning. Conversely, there are days I underestimate my glycogen depletion and wake up with very high BHB levels and very low glucose levels (i.e., BHB levels higher than glucose levels, when both measured in mM).

Final thoughts

I felt a bit like I was in unchartered territory because the literature on nutritional ketosis hadn’t really (to my reading) explored this level of extreme activity.  In future posts, I may write about other experiences and self-experiments, including my experience with exogenous (i.e., synthetic) ketones (which I did not use on this ride, but have experimented with on other rides – no, this is not “raspberry ketones” or other such gimmicks).

2017: You can read about one of my earliest experiences with exogenous ketones in this post.

Are carbohydrates necessary to produce 225 watts or more for hours on end? Yes. But, the key is knowing how much you need and when to take them.  A lower RQ at a given level of intensity means less demand on glycogen. In my experience, working with athletes and non-athletes, most tend to make two errors (for lack of a better word):

  1. They over-estimate their carbohydrate requirement, and/or
  2. They forget that no factor influences RQ – and therefore substrate requirement – more than dietary composition during lead up to event (or “life”, which is sort of the ultimate event).

Know your engine, first.  Then fuel it appropriately.

Photo by CloudVisual on Unsplash

Disclaimer: This blog is for general informational purposes only and does not constitute the practice of medicine, nursing or other professional health care services, including the giving of medical advice, and no doctor/patient relationship is formed. The use of information on this blog or materials linked from this blog is at the user's own risk. The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard, or delay in obtaining, medical advice for any medical condition they may have, and should seek the assistance of their health care professionals for any such conditions.


  1. “1. Just because we are fond of something, does not imply we are better off consuming it to our heart’s content. Remove the social stigma from heroin and people are pretty fond of it when they’ve had a taste. Is it good for us? Unlikely.”

    No, but addiction must have some roots in evolution. Dopamine is important for feeling well. Is heroin an example of overstimulation of the natural system of feeling well (dopamine regulation)? The same might hold true for high glycemic carbs. “Unnatural” products create a runaway system.

    “2. We evolved in a pretty food-scarce environment, so evolutionary pressure was going to favor an affinity for foods that enable us to store energy better (e.g., fructose).”

    Do you have any good source to find out what the climate was like in East-Africa 200.000 tears ago?
    If indeed the carbs were a sign of lack of food, the combined effects of 1&2 might work as a double edged sword to maximize fat accumulation eating high glycemic carbs.

  2. I have read your website for hours and hours but need help on where/how to start. My daughter is 19, a division I college runner (6k), and has become unhealthy the last year. She gained 10 lbs, is now insulin resistant, has high cholesterol (240), high triglycerides (131), LDL (151), HDL (69). She has been gluten free, dairy free, sugar free since May. No improvements. Her BMR in May was 1890. She fluctuates her calories between 1600 and 2000. She is currently red-shirting this cross country season but we need help. We have seen so many docs. One doctor prescribed D-Ribose. Is this safe when trying to cut out sugar? She has two weeks off from running in Nov. Is this enough time to adjust to NK?

  3. First off, your website is an absolutely fantastic resource and you’ve done some incredibly interesting work that supports ketosis as a potential way to treat diabetes, metabolic syndrome, cancer and enhance athletic performance. I think I recall you mentioning an interest in the administration of exogenous ketone bodies as a way to bypass the fairly extreme dietary changes needed to achieve sustained dietary ketosis. I was wondering what your opinion was on the use of activators of AMPK to increase fatty acid oxidation, resulting in an increase in circulating ketone body levels. I would think that AMPK activators would help an individual transition from a physiological state that relies on glucose to one of ketosis by helping to mobilize fatty acids for catabolism. For example, if someone is transitioning to a ketogenic diet exercise (naturally activates AMPK) with exogenous AMPK activators might make it easier for the body to access its fat stores and allow them to achieve ketosis more quickly. I wouldn’t think an activator of AMPK like Metformin would work particularly well, given that it is not a direct activator of AMPK and inhibits the ETC, but I would think something like salicylate (a metabolite of acetylsalicylic acid that activates AMPK directly) might work well in augmenting the body’s ability to transition to ketosis. I’m just curious to hear what your opinion is on this matter. Thanks!

    • It has been proposed, as you note, that AMP kinase activation (partially) explains the efficacy of metformin and some of the purported anti-cancer benefits. It may also explain why fructose in excess can be harmful for susceptible folks (the opposite effect). Exogenous ketones, of course, bypass the entire system.

  4. One has to wonder if Metformin may be beneficial because Cancer is yet just another aspect of diabetes? Seems that Cancer is yet another problem with sugar metabolism and insulin response (like so many other issues). Perhaps if we all stopped eating quite so many carbs we’d see a noticeable decrease in cancer, diabetes, etc.

    • As you may know, patients with T2D who take metformin have better cancer outcomes than matched T2D who do not. Proves nothing, but worthy of investigation.

  5. Dr. Attia,

    I’ve recently discovered the ketogenic diet and I’m fascinated by it (I’ve also read Phinney & Volek’s work.) I’ve been trying to get into ketosis (as monitored by the Abbot blood monitor) and I seem to be missing it. Here’s my simple question: Can too much protein consumption keep me out of ketosis?

    I imagine that has been asked and answered elsewhere so my apologies for asking again. I don’t recall if I’ve read anything on the issue, but perhaps Phinney/Volek have explained it. Thanks

    Kyle Norman

  6. Hi Peter,

    Apologies if you have already covered this but do you have any recommendations on Blood Monitoring kits?


  7. Hi Peter,

    Just achieved Ketosis (and feeling GOOD) according to Ketostix and also just purchased the precision xtra. I have been active and athletic my entire life and continue to ride and swim but unable to run due to back issues but am very healthy otherwise. Over the last ten years I have crept up 20 pounds mostly around my waist, I am now 54 and hope to continue working out at for as long as possible. Should I expect any age related complications in my performance, fat loss and/or nutritional ketosis state? Also when do we need to worry about ketoacidosis?

    You’ve become a long needed inspiration!

  8. Hi Dr. Attia,

    Congratulations for your blog. I just discovered your website and I am FASCINATED by the quantity and quality of all the information you provide. Last year I was on the keto diet for a month and lost about 20 pounds, now I have started again and I am on my 17th day, feeling great, with reduced appetite and with one question. I have read that coffee increases insulin production, does this happen even if there are less than 20 gramms of carbs in my diet? I only drink a cup of coffee in the morning with a tbs of coconut oil. Maybe the answer is somewhere in the blog, but I have not read it all yet.

    Thanks a lot!


  9. Hi doctor, I’ve searched for information on medium chain triglycerides but couldn’t find it and I know that you have discussed it somewhere. Can you guide me to any of your discussions on the subject? I am interested in the fact that coconut oil is being used for the treatment of Alzheimers. Thanks.

    • I have not written “formally” about MCT, but have referenced them in different places throughout the blog and comment. Lots on line, also.

  10. Excellent information! We are just starting out from a very sedentary lifestyle to working out (strength and cardio) an my husband was freaking out that he gained weight the first few days, and lost to net zero/no loss for the week – first time since July 1st he didn’t lose weight in a week. With my strength training routine I notice I do gain weight, although it balances it out through the week. As long as I’m still losing inches I don’t mind as much! Valuable information, here, thank you!

  11. Dear Dr. Attia,

    I have a somewhat strange question about nutritional ketosis. A week ago I took the plunge and forced my body to switch over into nutritional ketosis. Here is the weird part, since I was a teenager 30 years ago I have known that dark urine means I am becoming dehydrated and I need to drink more water. Normally when I get up in the morning I will do my business and my urine would be relatively dark despite the fact that I frequently would drink a glass of water close to bed time. Sunday morning I realized my urine was quite light in color but did not think to much of it, however I also realized I do not get nearly as thirsty when working out on the elliptical machine as I was for the past year and I am drinking less water while working out. I tried researching online to see if metabolic water could be having such a large effect but did not find any studies or even anecdotal reporting on the subject. I don’t know of any reason why unusually light colored urine would be unhealthy, but I am not a medical doctor and do not know what to make of this change in my kidney function, or even if it is a change in my kidney function. When I tried to work out Saturday it was a terrible slog and I gave up after 20 minutes but today I worked out for 70 minutes and felt as if I could have gone on much longer if I had wanted too. Even so I drank no water while working out today, I only perspired lightly (we keep the heat low in the winter so the house was 62 degrees F for my workout) and after the workout I used the restroom and again my urine was very pale in color. I know you don’t give medical advice over the internet, but is this something I need to make an appointment with my General Practitioner about?

    Thank you for all you do, if not for your inspirational work I would never have been brave enough to take the step from no sugar to low carb to nutritional ketosis from late January 2013 to last week when I committed myself to 28 days of nutritional ketosis.

    Allen W.

    • Hard to say, Allen. It turns out urine color is not (despite what seems obvious) a reliable indicator of hydration status. A urine specific gravity is much better. So if you have concern, best to see your doctor.

  12. Dear Dr Attia

    I know you are a busy man, so I will try to keep this as short as possible. I must say right off the bat, that I am not like the average reader of your blog, who are admirably intelligent, so please forgive any statement that reeks of ignorance. I would like to draw attention to Advanced Glycation End-products (AGEs). I first came across AGEs in Dr William Davis’ ‘Wheat Belly’ book. They are said to cause anything from atherosclerosis to dementia. They are essentially useless debris that result in tissue decay as they accumulate in our body, purportedly contributing to the aging process and are perhaps a major cause of diabetic complications (neuropathy etc.). They are also found in much higher amounts in older people. AGEs are also a by-product of high blood sugar. To better describe AGEs, I would like to quote an excerpt from ‘Wheat Belly’ : “The greater availability of glucose to the body’s tissues permits the glucose molecule to react with any protein, creating a combined glucose-protein molecule. Chemists talk of complex reactive products such as Amadori products and Schiff intermediates, all yielding a group of glucose-protein combinations that are collectively called AGEs. Once AGEs form, they are irreversible and cannot be undone. They also collect in chains of molecules, forming AGE polymers that are especially disruptive.2 AGEs are notorious for accumulating right where they sit, forming clumps of useless debris resistant to any of the body’s digestive or cleansing processes.” INTERESTINGLY, AGEs are also found in high quantities in animal products (meat and fats). Here is a paper about AGEs and their content in various food, So I wonder, if a diet like yours, which is high in saturated fats, may also yield a high AGEs content. Bacon, especially, is extremely high in AGEs. High temperature cooking methods also dramatically increase the AGEs content in food. I also practise a diet similar to yours, which is LCHF. I worry that, such a diet may have the unexpected disadvantage of coming with a high AGE content, and may thus increase the risk of atherosclerosis (and other complications). May I suggest that you take AGEs into consideration in your NuSi efforts ? What is your take on this ? Sorry for the lengthy post and thank you for your time.

    P.S. You are a great inspiration, it takes tremendous courage to admit one is wrong and go against the prevailing dogma and carry out self-experimentation. If only we have more people like you in the medical profession.

  13. Hi Peter,

    Thanks for all the time and passion you put into this over the years. Over the past few months I have successfully lost 35+ lbs (28 fat) through NK. After studying much of your blog I am now adjusting further by increasing my fat intake and lowering my proteins. Question: I have a hunch that human ketones (acetone, acetoacetic acid) are not chemically the same as raspberry ketones (C10 H12 O2). If one were to ingest true, pure raspberry ketones (C10 H12 O2) would that provide any physiological benefits identical to human ketones? (I was considering an experiment by using raspberry ketones for the 2 days following cheat days to try to maintain my ketone level and responses while my body adjusts down from the carbs of a cheat day).

    Joe Richardson

  14. Staying in nutritional ketosis is sometimes counterintuitive. Using the calculator on the above website which give the ketogenic ratio for example, If a person went over in carbohydrate and to a lesser extent protein they could still stay ketotic if they compensated with more fat. Even though this would be much higher in calories they would stay in nutritional ketosis. The ratio correlates strongly with the blood ketones.

  15. In an attempt to get into ketosis many people have experienced pounding heart especially at night.
    Why this could be? Thyroid? Electrolytes? And how to tackle it?

  16. That’s true Peter. On the other hand what people like yourself are doing on blogs is way better than what many doctors are doing in practice. Like increase in LDL-C on a low carb diet, pounding heart issue also seems quite puzzling for some people, especially when adding carbs back seems to fix the problem in both cases for many people but they are kicked out of ketosis and stop losing weight. Some have reported to have fixed heart pounding by adding sodium also. Not sure if one can supplement more than 2-3 grams of sodium if this much does not work?

  17. You mention a metabolic response to inflammation as a result of exercise and refer another commenter to systemic inflammatory response syndrome. I searched your web site and your Coming Soon page and didn’t find anything regarding the metabolic response to infection or inflammation. Thus my question: can an infection knock one out of ketosis — cause the BK to drop down to 0.2 and the BG to remain higher than baseline — and for a person to gain weight, even when adhering to a LCHF diet?


    • I meant to say — gain weight that is not just water weight, but weight around the waistline. And in rereading your post and some of the comments I’m thinking that the SIRS response to inflammation from exercise is not much different from a metabolic response to infection? Just would like it see it all fleshed out in a future blog post. Plus maybe the implications are that when one is having an SIRS response to infection, perhaps it’s important to introduce some carbohydrates in the diet just as athletes do in their glycogen recovery phase?

      Sorry if my questions are garbled.

    • Sorry to be a serial commenter! I need to continue to clarify: when I’m talking being kicked out of ketosis and gaining weight due to infection, I don’t mean a transient experience but rather one lasting 2 -3 weeks. Also I researching metabolic responses to infection I stumbled on the following article from 1981 and don’t have the training or background to interpret it fully. It does seem to be a somewhat different process than what’s described in the wiki for SIRS. It suggests that there are two parallel responses to infection — immune and metabolic:
      The American Society for Clinical Nutrition, Inc
      Effect of diet on the metabolic response to infection: protein-sparing
      modified fast plus 100 grams glucose and yellow fever immunization.
      B R Bistrian, D T George, G L Blackburn, and R W Wannemacher


      The metabolic response to yellow fever immunization was investigated
      in four obese subjects who were consuming a protein-sparing modified
      fast plus 100 g glucose (PSMF + 100 g) for 3 wk. Fasting, 1/2, 1, and
      2 h postprandial values for insulin, glucagon, glucose, lactate, beta
      hydroxybutyrate, acetoacetate, and free fatty acids were assessed
      before and the 1st, 3rd, and 5th day postimmunization. The hormone and
      substrate response to dietary protein plus glucose was a substantial
      rise in insulin (p less than 0.005), glucose (p less than 0.005), and
      fall in free fatty acid and ketone levels (p less than 0.005). These
      results are distinctly different from the response to dietary protein
      ingestion only (PSMF) determined in a previous study which was a
      slight rise in insulin and glucose and slight fall in ketone bodies,
      but a substantial rise in glucagon. The only significant (p less than
      0.05) change following immunization in the PSMF + 100 g was a rise in
      serum glucagon on day 1. During the PSMF significant elevations in
      insulin and lactate and falls in serum ketones were noted
      postimmunization. The metabolic response to mild infection is
      dependent on the diet consumed. These differences may have a clinical
      impact when the infection is severe, but this possibly requires study
      in an experimental infection of greater severity.

    • Yes, infection can easily cause an adrenal response, which increases hepatic glucose output, which can knock you out of ketosis. A server enough infection causes a SIRS response, which almost invariable leads to weight gain — virtually all of it being third-space (interstitial) water weight.

  18. Dr. Attia,
    Your information is invaluable! I had a question and I’m not sure is the right blog post but here goes. I’ve been paleo for 4 years and 6weeks ago started a keto program. I’ve noticed that my blood glucose is around 65 at any give time of the day and my blood ketones vary from 0.1-0.4 and urine ketones are not present. . I’m not sure what my body is using for fuel. I lift weights around 1-2 me a week and do Jujitsu 1-2 times a week. Can you shed some light n what my body is using as its main substrate for fuel?

  19. Dr. Attia,

    I wanted to know your opinions about my training regimen. I would really appreciate your advice.

    I am a 25 years old male from Croatia and used to be a professional tennis player. Until 5 years ago, I trained 6 hours a day and my diet was of course mainly comprised of carbohydrates. It was three huge meals consisting of either cereals with milk, pastas or pizzas. Five years ago I moved to the States when I was offered an athletic scholarship to play for a university. I moved to the States and played there for three years.

    Two years ago I stopped playing tennis all together to focus on studying and went from 86kgs (which is my playing weight), to 100kgs. I kept the same diet as in my competitive days, and I think that the processed foods from the US didn’t help. I became depressed, brain fogged and was always hungry.

    My thirst for nutrition knowledge started after I read about the “Steak and eggs” diet. After a year of going strict keto (except sometimes weekend carb reloads) and lifting heavy weights, I am back to a comfortable 90kgs. I eat a huge meal in the evening and fast for pretty much 20-22 hours each day without a drop of energy. I eat lots of eggs cooked in butter or lard, red meat and some vegetables on the side. I can lift fasted without any problems but don’t think I will be able to keep this diet when I start playing tennis again this summer. I am happy to have regained metabolic flexibility but would like to incorporate carbs in my tennis regimen and keep fat burning to a maximum.

    I wanted to know your opinion about using boiled potatoes (because of high satiety index) as my only source of carbs during tennis practices (might it be enough for the sweating of minerals)?
    Would it be optimal to start playing fasted and then eat them during practice or eat them before practice ?
    Also, would you think coconut oil would be a good enough source of energy during practice under hot conditions?


    Marko Skoric

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