The ketogenic diet has been getting a lot of buzz in recent years. That is plainly obvious with every visit that I make online to read over comments from Hypothyroid Mom followers. It seems like one after another, people are raving about keto for finally helping them lose stubborn fat. With all the rave reviews, however, the truth is that I’ve also heard from hypothyroid readers, more often women than men, feeling sick and even gaining unwanted weight on keto. It is clear to me that the traditional keto diet is not the wonder weight loss cure for everyone, especially those of us with hypothyroidism.
Are there particular modifications for people with hypothyroidism so that everyone wins with keto? That was my burning question.
And there entered this OB/GYN.
Written by Anna Cabeca, DO, FACOG
I get asked a lot about whether a ketogenic diet – a very low carb diet – improves symptoms for women having thyroid disease, or whether it makes symptoms worse.
My own medical opinion, given decades working with women over 40 having hormone balancing challenges, is that a traditional ketogenic diet may not be right for many women with thyroid disease. The good news? I have found a few important modifications that can be incorporated with keto that address its possible negative effects.
Let me talk a bit more about this and how I’ve enhanced the traditional ketogenic diet to best serve women over 40.
The potential problems with keto
A ketogenic diet is a very carb-restricted diet that is also high in fats. The reduction in carbs changes the “fuel” your body burns, from glucose (generated by your body in response to all the carbs we all tend to consume) to instead burning fat. This metabolic state of fat-burning is called ketosis. Because your body starts to burn fat, the only available alternative fuel source, a keto diet is known as a great weight loss diet.
This switch in fuel source can actually be measured by testing for something called ketones, either in the blood or urine. When you are testing positive for ketones that means you are burning fat. It also means you are producing less glucose (so no more blood sugar spiking!) and improving your insulin control.
There have been many studies which have scientifically shown that a ketosis state not only supports weight loss, but that it also may reduce blood sugar issues such as insulin resistance and diabetes, may support improved memory and overall brain health (and may reduce your risks for developing Alzheimer’s disease), may reduce epileptic seizures, and finally may even help fight cancer.[1-8]
All of these are things that sound pretty good, right?
But…it turns out that it is the reduced production of insulin that some thyroid experts have expressed concern about when it comes to people having thyroid disease trying traditional ketogenic diets.
Why the concern? Because too little insulin can impact the liver’s ability to make T3 out of T4.
So that’s the first concern we need to talk about.
And the second concern expressed about traditional keto is relating to the state of ketosis itself. Especially for women, remaining in ketosis too long on a ketogenic diet can create way too much acidity in the body. This can be very inflammatory.
So these two concerns (the possibility of lower T3 and increased inflammatory acidity) are the likely culprits when you hear a woman – especially one having some underlying inflammatory issue already, like thyroid disease – having problems as she tries to adhere to a typical ketogenic diet. You might also hear that she has suffered weeks of keto-flu and finally has just given up. Or you might hear she has felt so irritable and keto crazy about the entire experience that she has not only alienated herself from her entire family – including the pet dog – with a very witchy attitude… but has binged on chocolate chip cookies and wine for 3 days as well (before giving up on the diet completely)!
I have dozens of clients who have experienced this result. The traditional keto diet has made them miserable and worsened their thyroid symptoms.
Now, we are all very biologically unique…so some women will do fine on strict keto. Especially women who have no underlying inflammation and who also have very healthy hormone balance…so this would be a woman who has no toxicity challenges, no gut imbalances, no stress issues and the like…know many of those? I don’t!
The bottom line is that most women need some important modifications to the keto diet in order to feel well and remain compliant to its somewhat strict disciplines. And those modifications need to address the two concerns (potentially lower T3 and increased inflammatory acidity) as well.
Listen to your body.
Research has shown that there can be a reduction in T3 levels when a woman is on a ketogenic diet. But does that necessarily equate to women feeling less well? That depends on many other things going on in a woman’s body, in particular her overall hormone balance and inflammatory status. A woman needs to listen to her body, and yes…she needs to know her overall thyroid numbers, whenever she tries any new diet or lifestyle intervention.
What I have found is that if a woman adds certain foundational hormone balancing support to a keto diet, that in most cases her TSH level won’t increase and she will continue to feel well or better!
This even happened to me.
I personally saw a greatly elevated TSH level after exposure to incredible mold toxicity (a result of my home being hit – for the second time – with a hurricane). While I’ve had thyroid issues for many years my TSH really shot up, to 5.07 mIU/L in Dec 2017 (along with repeated mold exposure add in the stress from 5 different moves!)! After getting back – strictly – on my Keto-Green program my TSH measured 0.55 mIU/L in October of 2018. And my free T3 also increased to a healthier level.
And what about the second keto concern? Women on a traditional keto diet often suffer from increased inflammation and acidity due to remaining in ketosis too long.
That’s where an alkaline foundation helps out.
A Thyroid-Friendly Keto Diet
If you are looking for information on the basics of the diet, I wrote this article here at Hypothyroid Mom.
Here below you’ll find the key modifications that I’ve found to make all the difference for women with thyroid disease. If you’ve already tried keto and didn’t feel your best, retry it with these modifications. You’ll be surprised at the difference a few teaks can make.
The first major difference is that women shouldn’t dive into the ketogenic diet on day one. Instead, focus on developing a healthy foundation that includes:
- Maintaining an alkaline pH – This is core to counter the inflammatory acidity seen in ketosis! Keto-only diets force women to stay in ketosis too long and become acidic, which actually creates inflammation. This can result in your body holding on to its fat stores so you won’t lose weight (if that’s your goal)…and the increased inflammation can worsen your thyroid symptoms. For optimal health and wellbeing strive for an overall net alkaline producing diet versus the typical Western (high carbs!) net acid producing diet. Getting alkaline also helps us reset our circadian rhythm, which helps us sleep better and improves our mood. It supports our body in regulating our hormones, including our thyroid hormone, in a more productive fashion too. Note that this net alkaline producing effect is also significantly impacted by many non-dietary elements as well (stress being a big one)!
- Incorporating important lifestyle changes that directly support our two thyroid-impacting regulatory hormones, cortisol and insulin. This includes:
- Improved stress management – Many women can’t get into ketosis until they learn better stress management techniques. We can’t always remove our stressors, but we definitely can learn how to reduce our stress hormone, cortisol, to healthier levels (cortisol effectively puts the brakes on your thyroid metabolism, digestion and immune processes).
- Supporting our adrenals with adrenal adaptogens. Too much stress burns out your adrenals. Your adrenals normally focus on mundane things such as metabolizing nutrients and producing needed hormones. Maca is one of my favorite adrenal adaptogens.
- Improving our sleep. Our circadian rhythm is critical to hormone production and our overall health and mood.
Addressing the gut dysfunction that is common with thyroid disease. Support thyroid/keto digestion issues (low stomach acid, malabsorption of key nutrients such as zinc, Vitamin D, selenium; leaky gut, constipation due to slow metabolism, etc.) with high quality probiotics, digestive enzymes, and natural detoxification strategies.
Reducing environmental toxins from foods (eating clean and organic, without added hormones, GMOs and chemicals), personal care products (how many endocrine disruptors do you apply to your body daily?) and the home. Ketogenic diets do not include this as an important step but women tell me all the time that this is the key aspect to their achieving alkalinity as well as hormone balance.
Cutting out inflammatory food sensitivities. Most ketogenic diets focus on just lowering gluten intake but do not require the removal of gluten as well as other inflammatory foods. I have found that women in particular do better on a diet that excludes the top inflammatory foods such as gluten, dairy, sugar, and processed foods.
Incorporating the health benefits of intermittent fasting is also key. Many keto diets include some aspect of intermittent fasting as there are numerous studies that support the health benefits (improved insulin sensitivity, reducing oxidative stress) and improved metabolic benefits of fasting (particularly true with the type of fasting that I recommend in my Keto-Green program which is to increase your fasting window between dinner and breakfast, known as a 16/8 fast). I don’t advocate the prolonged 24 hour type of fasting that you’ll find in many keto diets, in particular for those having thyroid disease. It puts too much stress on the body. If you have underlying issues with insulin resistance or blood sugar it is important to discuss any type of dietary change – including intermittent fasting – with your physician.
And finally, let’s incorporate the reality of living into our diet and lifestyle! I’ve seen some thyroid clinicians state that staying in ketosis too long isn’t healthy for those with thyroid issues given that it may lower T3 levels. But frankly, women on my program don’t stay in ketosis for weeks at a time, not even days at a time in many cases. We bounce in and out as there are many dependencies beyond carbs that affect ketosis (such as stress level, sleep, toxicity and so much more).
This is an important point, that there are things beyond carb restriction that can impact ketosis. I’ve found that women, for example, who are under chronic stress may never be able to get into ketosis no matter how much they restrict their carbs.
So how challenging it is for you to get into ketosis, how long you stay there, and how it makes you feel is unique to each of us (and can change over time). You’ll have to experiment a bit by working on the foundational pieces noted above and also perhaps by tweaking your intake of carbs.
Generally, people need to be at around 20-40 grams of total carb per day to get into ketosis. But if you’re a women under stress that might not be low enough to get into ketosis…but don’t just keep lowering the carbs, you need to deal with the stress (and underlying cortisol issue and adrenal burnout). In talking with clinicians focused on thyroid disease and working with ketogenic diets for their patients and clients, most would say not to go lower than 20 grams of total carb per day, in conjunction with their thyroid hormone medication.
I’m not looking at the number of daily carbs, but at the percentage of one’s daily food intake or “plate”. It is much easier and intuitive to do this. I target 5-10% of the “plate” to be healthy, slow-burning carbs (and this equates to generally around 20-35 grams of carbs).
The one caveat to these healthy target carb levels might be someone having an overactive thyroid who may not want to risk further weight loss.
I use an 80-10-10 philosophy. For optimal results I like for women to stay Keto-Green about 80% of the time, fast about 10% of the time (so do some periodical periods of intermittent fasting, but don’t live with those restrictions each and every day), and feast about 10% of the time. Yes! Feasting is so important as it is typically time we bond with family and friends…and we all need to treat ourselves from time to time.
About Anna Cabeca, DO, FACOG
Dr. Anna Cabeca is an Emory University trained gynecologist and obstetrician, a menopause and sexual health expert, international speaker and educator, and author of the USA Today bestseller The Hormone Fix. In a survey of more than 500 women following her Keto-Green program 94.95% felt that their energy levels had improved. And while blood testing isn’t part of the program, many women who did have testing improved their numbers – including their thyroid levels. Her 10-Day Breeze Through Menopause Masterclass is free right now for Hypothyroid Mom followers.
References:
[1] Paoli, A., et al. Beyond weight loss: a review of the therapeutic uses of very-low-carbohydrate (ketogenic) diets. Eur J Clin Nutr. 2013 Aug;67(8):789-796.
[2] Rosedale, R., et al. Clinical Experience of a Diet Designed to Reduce Aging. J Appl Res. 2009 Jan 1;9(4):159-165.
[3] Shaafi, S., et al. Ketogenic Diet Provides Neuroprotective Effects against Ischemic Stroke Neuronal Damages. Adv Pharm Bull. 2014 Dec;4(Suppl 2):479-481.
[4] Allen, B.G., et al. Ketogenic diets as an adjuvant cancer therapy: History and potential mechanism. Redox Biol. 2014;2:963-970.
[5] Yancy Jr., W.S., et al. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab (Lond). 2005;2:34.
[6] Murphy, P. et al. The antidepressant properties of the ketogenic diet. Biol Psychiatry. 2004 Dec 15;56(12):981-3.
[7] Gasior, M., et al. Neuroprotective and disease-modifying effects of the ketogenic diet. Behav Pharmacol. 2006 Sep;17(5-6):431-439.
[8] Rogovik, A.L., et al. Ketogenic diet for treatment of epilepsy. Can Fam Physician. 2010 Jun;56(6):540-542.
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