Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...Tell Me More
Judging from our blog and sales metrics, women make up the largest group of recent entries into the diet. This is great, but it also comes with a small wrinkle: Just like they should do with fasting, most women need to take special precautions when implementing a ketogenic diet.
To begin with, one of keto’s main benefits is also its biggest stumbling block for women: The inadvertent reduction in calorie intake and massive increase in satiety.
It’s the quality that makes ketogenic diets so effective for weight loss, particularly in the obese and severely overweight. And that satiety, that provides a psychological boost. You’re not just not hungry. You’re not hungry because you’re consuming your own body fat. You eat fewer calories than you were because all the food is coming from inside the house. That’s powerful, and it perpetuates itself, leading to even more weight loss and making keto that much more sustainable.
But it’s a double-edged sword. Premenopausal women have a greater sensitivity to reduced calories than other human variants. As I said previously…
Biology cares most about your fertility. Can you reproduce? Can you produce healthy offspring that survive to do the same? It’s not fashionable to say it, but it’s the truth: Physiologically, ancestrally, evolutionarily, these things come first.
And from that perspective, a woman’s situation is more precarious than a man’s.
You have a finite number of eggs, or “chances.” Men have an almost infinite supply of sperm.
When you are preparing to get pregnant, your body needs extra nutrients to build up a reserve and “prime the pump.”
When you are pregnant, the growing baby needs a reliable and constant stream of nutrients for almost a year. After a man gets someone pregnant, his biological involvement with the growing baby is done. What he eats has no impact on the survival of the growing baby.
After you’ve given birth, the growing newborn needs breastmilk. To make that milk requires additional calories and extra doses of specific nutrients. Modern technology allows us to skip nursing and go straight to the bottle, but your body doesn’t “know” that.
It all points to women being more finely attuned to caloric deficits. For example, women’s levels of ghrelin, the hunger hormone, are quicker to rise after meals. They get hungry quicker.
This isn’t just relevant for parents or parents-to-be. Even if you’re not interesting in getting pregnant and having kids, or you have children and aren’t planning on any more, the ability to do so is strongly connected to your health. Reproductive health is health. As far as your body’s concerned, having kids is the primary goal and you need to be ready to do it as long as you’re able.
With that in mind, how can we avoid the common pitfalls women face on keto?
Luckily for you, I have a team of brilliant women with a ton of keto experience. We put our heads together and came up with some suggestions:
This has three effects:
First, it upregulates construction of your fat burning machinery. It hastens the adaptation of your mitochondria to the new fuel source by boosting AMPK.
Second, it helps ensure you aren’t working from a caloric deficit. This sends your body a signal of abundance, which means it won’t dive into metabolic conservation mode and hang onto fat stores for dear life.
Third, it gives you a psychological boost. It’s a nice way to realize that you can eat more fat than you thought useful and still lose weight and experience health benefits. It also helps break through the psychological barrier many of us have with eating fat, thanks to growing up in the “low-fat-everything” era. Giving yourself permission to eat a lot (maybe even “too much”) fat at the beginning swings the pendulum strongly in the other direction so it can settle comfortably in the middle where it belongs.
This big increase in fat shouldn’t stay unless you’re trying to gain weight. As you get better at generating and burning ketones and, later, body fat, you can start chipping away at your own adipose tissue and reducing the amount of dietary fat. Continuing the extra fat intake, however, may be important for those who are underweight or who are using keto therapeutically. This may go for any of us though: if you’ve been eating a low-fat diet up until now, a seeming “big increase” in fat intake might just help you attain what would be considered normal keto levels.
Make sure you’re eating the particular fats that boost AMPK (which builds fat-burning mitochondria):
Remember how a a major benefit of keto is inadvertent calorie restriction? Don’t try to double up by restricting them further.
Look. If you’re not buying this, give me three weeks. Three weeks of ad-libitum eating. Don’t gorge yourself. Don’t put a stick of butter in your coffee just because. But don’t calorie count. Don’t weigh and measure.
Eat to satiety. Eat until you’re not hungry anymore.
Don’t eat until you’re bursting.
It’s not a fine line I’m talking about here. You have a lot of wiggle room between “undereating” and “gorging.” It’s closer to a wide walkway. Most people eating a basic whole foods Primal keto diet won’t have trouble staying between the lines. Trust that your subconscious systems will regulate calorie intake for you.
Don’t try to override the system. Give it a chance to work.
Even many men, who tend to be more impervious to metabolic insults, suffer when combining extremely low carbohydrate diets with intense fasting or constantly compressed eating windows. Their calories get too low, too quickly, for too long.
The point of keto is to boost fat burning. The point of fasting is to boost fat burning. When you boil down to it, they’re shooting for very similar things. Combining the two seems like it would supercharge the benefits, and it often can, but that’s not always the case—particularly for women, particularly right when you’re starting.
Besides, if you throw both of them in at once, it becomes hard to disentangle the various inputs to determine what’s causing the harm (or benefit). Introduce one major shift at a time—fasting or keto—and give yourself a clearer view of the situation.
Fat bombs can be helpful allies for hard-charging keto athletes who need as many calories as possible just to maintain homeostasis. Those folks usually achieve adequate micronutrition due to the sheer volume of food they take in, so there’s “room” for spoonfuls of coconut oil and shot glasses of olive oil. If that doesn’t describe you, don’t do what they do.
If you’re going to do a “fat bomb,” make it as nutrient-dense as possible.
There’s an argument for super strictness at the outset. Sticking with keto for the first 3 or 4 weeks as closely as possible does wonders for fat-adaptation. But once you’re there, you’re good. The fat-burning machinery is built. Your mitochondria are good at switching between fat and glucose. Eating a homemade gluten-free cookie your kid surprised you with isn’t going to derail your entire keto journey. You will bounce back. You will be fine.
After all, the reason we all got into this keto thing is to improve our metabolic resilience. To be able to go off the rails and find our way back without an issue. This is the keto zone I talk about so much (and spend so much time in).
If you’re trying to stave off epileptic seizures, enhance the effect of cancer drugs, treat dementia, or need high ketone readings for any other medical reason, stay strict. Otherwise, don’t be so strict.
When the diet “isn’t working,” which of course usually means the person isn’t losing weight, there are three things you hear:
However, for a body that is under stress, less isn’t necessarily the answer. Sometimes your body needs more food period, perhaps even more carbs or protein specifically. This is why I cringe when I see people going straight from the Standard American Diet, or even from higher-carb paleo/Primal or the like, straight into hardcore keto plus IF and extreme calorie restriction all in one fell swoop. Your body needs time to learn how to power itself on ketones, so taking away all the food security at the same time can be incredibly counterproductive. And because women are inherently more sensitive to metabolic disturbances or signals of “famine” than men, they need to heed this warning in particular.
They say the slippery slope is a fallacy. Maybe in some cases, but I see one example that’s valid: the low-protein slippery slope. A lady goes keto, has poor results. She goes online, asks around, others suggest, “How much protein are you eating?” She drops protein. Gets worse. Drops protein a bit more. Suffers more. Soon she’s eating nothing but Primal Kitchen mayo, mac nuts, romaine lettuce, and a single egg. She’s so ketotic she’s peeing purple drink, yet her symptoms are only getting progressively worse.
Yes, protein is an oxaloacetate donor, which means too much of it can impair ketogenesis. Yes, people whose health requires high levels of circulating ketone bodies must limit protein, often more than they think. Yes, the classic epilepsy diets are very low in protein. But there is such a thing as too low a protein intake, especially for women who tend to eat less protein than men in the first place. Getting high ketone readings isn’t worth much if you’re losing muscle mass, lagging in the gym, and experiencing worse body composition shifts. I mean, what are we doing keto for, anyway?
As a pregnant woman building a human, you’ll need all the nutrients at your disposal. You don’t want to restrict anything nutritious. It’s no time to be experimenting. I don’t recommend keto for pregnant women unless they’re using it to treat a medical condition with the supervision of a physician.
As for breastfeeding, oxaloacetate is necessary for finishing the Krebs’ cycle and producing ATP from fat and glucose. Running out of oxaloacetate means we can’t make ATP from fat and glucose and need an alternate energy source: Ketones. Lactating women also use it to produce lactose, the milk sugar that provides much of the nursing baby’s energy needs. That means that lactating women can eat more carbs and protein and still remain in ketosis. It also means that eating a strict ketogenic diet extremely low in carbs and protein is likely to impair milk production.
While many women report remaining ketogenic while nursing without issue, there are a few case studies of breastfeeding women suffering lactation ketoacidosis, a dangerous condition where chronically low insulin prevents the cells from accessing blood glucose and promotes unchecked ketone production that make the body overly acidic. This can be life threatening. Triggers of lactation ketoacidosis have included starvation (don’t starve yourself or even fast while breastfeeding), twin lactation (feeding two increases the amount of lactation substrate you need to consume), and a low-calorie/low-carb/high-fat diet (bad combo).
I’d suggest opting for a regular old low-carb diet, Primal style. I wouldn’t worry about ketone production so much as eating enough calories.
Menopause is generally inflammatory; along with waist circumference, menopause status is an independent predictor of low-level inflammation and elevated hs-CRP (one of the most fundamental markers of inflammation). There’s a low level simmer going on, and it can cause a lot of problems. Diet can make it worse, or make it better.
High-glycemic diets—also known as diets high refined carbohydrates—are associated with more oxidative stress in post-menopausal women (for what it’s worth, the same is true in premenopausal women).Glucose loading actively impairs bone remodeling in postmenopausal women. The problem doesn’t go away just because you exercise, either. And it gets worse the higher your postprandial blood glucose goes.
In overweight post-menopausal women, high-fat diets (where the fat came from cheese or meat) improved atherogenic biomarkers compared to a high-carb diet. Both the cheese-based and meat-based diets increased HDL and Apo-A1; the high-carb diet did not.
Meanwhile, high-carb diets were persistently linked to chronic low-grade inflammation and an elevated risk of heart disease in postmenopausal women.Many studies also find that the glycemic load of a postmenopausal woman’s diet is a strong predictor of her fat mass. Remember that glycemic load is often a roundabout way of indicting carbohydrates without saying “carbohydrates.”
The message is clear: glycemic load matters more than ever for health in the menopausal and post-menopausal years.
Paleolithic diets, on the other hand, reverse inflammatory markers in postmenopausal women. This is the classic paleolithic diet: lean meat, fruit, nuts, vegetables, eggs, berries, and fish with no grains, legumes, sugar, dairy, potatoes, or added salt. 40% of energy from fat, 30% from protein, 30% from carbohydrate. Over 24 months, menopausal women on a paleo diet lost more fat, more waist circumference, and more triglycerides than those on a standard “healthy” diet.
As of yet, we don’t have enough focused research on keto in menopausal and post-menopausal women to offer much in the way of study confirmation. However, these patterns suggest that an even lower glycemic diet (keto) would likely be more effective still for health markers and weight maintenance in these decades.
Finally, going keto can pay huge dividends, but it must be done correctly—and women have less room for error. Hopefully, today’s post offers some helpful tips for making it work. This said, I’ll also offer the reminder that there’s no one version of keto that’s right for everyone (or every woman)—the same with Primal or any other way of eating. Just because your neighbor is drowning everything in sour cream and eating 4000 kcal/day in a 4-hour eating window and calling it keto doesn’t mean that’s what you have to do. Get comfortable with the fact that finding the way of eating that works for you is going to be a learning process. Hone your keto lifestyle with this guidance above—and a healthy dose of patience.