I’m continuing my crusade of keto mythbusting. Recently, there was keto crotch, then keto bloat, and today I’m returning to one of the O.G. myths—keto body odor. Yes, it seems detractors of the keto diet are hell-bent on making you think your body will become a stinky, bloated mess if you dare to drop your carbs below 50 grams per day…but is it true?
Here’s the spoiler: Yes, people in online keto diet forums occasionally complain about an unpleasant change in body odor when they first go keto. There is no scientific evidence that it actually happens, nor a clear, compelling explanation for why it would. Moreover, the anecdotal (and it’s all anecdotal) evidence suggests that if it does occur, it is rare and temporary. In other words, the whole idea of keto body odor seems to be exaggerated—shocking, I know.
That said, significant dietary changes can result in other physiological changes that may manifest in a variety of ways. Since nobody wants to be the stinky kid, let’s take this opportunity to look at what might be plausible about keto body odor and what to do if you think you’ve been afflicted.
What Causes Body Odor?
First, let’s clarify what’s meant by “body odor.” In the medical literature, the term is used in reference to aromas associated with breath, urine, feces, vaginal secretions, sweat (usually from the axilla, or armpits), and general bodily essence as it were. Because it’s such a broad term, the causes are also extremely varied. For the purposes of this post, I’m going to use the term “body odor” to mean aromas from sweat and general bodily funk, since that’s what’s usually meant by keto body odor.
Body odor arises when odorless compounds leave the body through glands in the skin and interact with microbes living on the skin’s surface. The microbes then release chemical compounds—what we actually detect as body odor. Typically, commercial deodorants target both pieces of the equation by using antiperspirants to minimize the excretion of the odor precursors and by creating an unfavorable environment for the microbes living on the skin. There is also a genetic component to how much individuals secrete compounds that cause body odor.
Although a huge industry is built around trying to help people mask their natural odors—and suggesting that body odor is always the result of poor hygiene—bodily scents are actually quite important. Just as other animals do, humans use olfactory cues for recognizing kin, making judgments about others’ personality traits and attractiveness, and even for detecting fertility. Although we rarely recognize it, the data suggests that smell probably factors into all our face-to-face social interactions.
Body odor can also result from illness. Before the use of sophisticated modern disease detection techniques, doctors were taught to use their sniffers as a diagnostic tool. Even today, smell can be an important clue that an individual is unwell. Often these odors emanate from the breath or urine, but certain infectious and metabolic diseases can be associated with distinctive body odors. In addition to perceptible body odor, the human olfactory system can detect infection and sense illness in others, presumably an important means of preventing the spread of communicable disease.
Diet and Body Odor
The whole notion that a keto diet can cause body odor rests on the assumption that how we smell is affected by what we eat. It turns out that there is scant evidence that that is actually the case.
When I’ve taken up the question of keto diet and body odor previously, I noted that there are really only two human studies that speak to this. One small study found that women judged men’s body odor more negatively when they ate a diet that contained red meat compared to when they abstained from red meat. However, the diets differed in other ways as well. In contrast, a different study found that women rated men’s body odor more positively when the men reported eating more fat, meat, and eggs, and more negatively when they ate more carbs. Hmm.
Nevertheless, the common belief persists that certain foods will make you stinky: garlic, onions, cruciferous vegetables, and spicy foods especially. However, there is no evidence that this is actually the case beyond the obvious bad breath and, ahem, flatus that these foods can cause. In fact, the one study I found on the subject reported that garlic counterintuitively improved body odor.
So, Can Keto Make You Stinky?
As you can see, there’s minimal evidence at best linking body odor to diet, and none of it has to do with the keto diet itself. Nevertheless, the belief that keto causes body odor persists…thanks to the few complaints from some in the keto community (and, just maybe, those who have nothing to do with keto but want to cause a stir). While I don’t want to dismiss anecdotal evidence out of hand, I have noticed that once people go keto, their diet is immediately to blame for every weird smell, twitch, or symptom. It’s remarkable really.
In the interest of fairness, let’s look at the explanations that are typically offered for why keto might cause body odor:
Is It the Protein?
The first hypothesis is that keto dieters smell funky because they’re eating a lot more meat. As I already mentioned, there are only two small studies that speak to this, and the findings conflict. The idea at work: protein metabolism yields ammonia as a byproduct (true), which builds up because of eating “too much protein,” resulting in body odor.
To which I object… First of all, it’s not necessarily true that going keto means eating more meat. My version of a keto diet certainly isn’t a steak-and-bacon fest—I still eat tons of veggies. If anything, my observation is that keto folks by and large remain fearful of eating “too much” protein lest it kick them out of ketosis. (The issue is not nearly so simple as that, as I’ve explained.) In any case, even if you’re eating a good deal of meat, a healthy liver should be able to convert the amount of ammonia generated into urea and send it off to the kidneys to be excreted as urine.
Maybe It’s the “Detoxing”?
Toxins such as environmental pollutants accumulate in adipose tissue, a.k.a. fat cells, and these toxins are then released into the bloodstream when people burn fat. Because the keto diet often results in increased burning of body fat, the theory goes that the body is “detoxing” all these pollutants, and that’s what causes body odor. Detoxing is a controversial subject, and while it is true that some of these toxins can be excreted through the skin, the actual amounts are fairly small (the majority get excreted via urine and feces). Plus, it’s not evident that the toxins that are excreted through the skin cause any particular odor. And wouldn’t any diet that actually does what it’s supposed to—i.e. burn fat—be subject to the same “stinky” detox effect? I think we can safely chuck this claim.
Are Ketones a Cause?
Maybe ketones themselves make you smelly? This one has the most potential validity, as it’s well documented that acetone—one of the three ketone bodies—gets excreted when you’re in ketosis. However, it’s the cause of the familiar keto breath, not body odor per se. I’ve seen no evidence linking acetone to actual body odor.
What To Do About It
Ok, I hear you saying, “Mark, I see that you’re skeptical, but I’m telling you… I stink!” What can you do about it?
Well, since there isn’t a clearcut cause, I can’t give a clearcut answer, but I’ll tell you what the general wisdom says:
First, you can support your body’s own detoxification pathways as I describe here. Your body should be able to do a fine job taking out the garbage—it’s designed to do so and is efficient at it—but hey, why not drink some coffee and throw some broccoli sprouts on your salad. This is a “can’t hurt, might help” situation.
Same thing goes for taking some nice epsom salt baths, another common recommendation. Whether there is any truth to their detoxifying nature, you’ll get a nice dose of transdermal magnesium with a hefty side of relaxation. Throw in some essential oils and olive oil and soak your cares away… hopefully taking some of the b.o. with it.
You can also experiment with eating less protein and more carbs, but I do see potential downsides to both. You definitely don’t want to eat too little protein, since it serves such a vital role in healthy functioning, and you don’t want to add back too many carbs if being in ketosis is your goal. That said, especially with regard to the protein you probably have room to play around, so feel free to experiment if you want. I’m not overly optimistic that this is the answer, but I’m always a fan of finding what works for you.
Or, take a wait and see approach. Most keto side effects come and go as people become keto-adapted. If your problem is keto breath, not body odor per se, you can try chewing on some fresh herbs or taking chlorophyll supplements, but these will just mask the issue.
Lastly, if it is very noticeable and very bothersome, you can—and probably should—consult your doctor. If you are excreting significant ammonia, which usually happens via the breath, this is a sign of liver or kidney problems that need to be diagnosed asap.
The Bottom Line…
Because switching to a keto diet can initiate a profound metabolic shift, some people might experience side effects. And, sure, it’s conceivable that transient changes to body odor might be one of them. The lack of evidence that body odor is strongly affected by diet (as well as my own experience interacting with the thousands of people in my community who have tried keto) leads me to believe that this is a minor problem at most—and one that most people won’t experience at all. If it’s affecting you, feel free to try to solutions I described above. They might not resolve the problem immediately, but at least they’ll likely have other positive benefits.
Ok, what say you? Are your friends giving you a wide berth now that you’re in ketosis, or are you chalking this up to yet another thing the haters are blowing out of proportion?
Groyecka A, Pisanski K, Sorokowska A, et al. Attractiveness Is Multimodal: Beauty Is Also in the Nose and Ear of the Beholder. Front Psychol. 2017;8:778.
James AG, Austin CJ, Cox DS, Taylor D, Calvert R. Microbiological and biochemical origins of human axillary odour. FEMS Microbiol Ecol. 2013 Mar;83(3):527-40.
Natsch, A. What Makes Us Smell: The Biochemistry of Body Odour and the Design of New Deodorant Ingredients. CHIMIA Intl J Chem. 2015 Aug;69(7-8):414-420.
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According to the “good scientists” of the Kellogg company food lab, an unprecedented number of young people are walking around with bloated guts and colons packed to the brim with impacted fecal matter, and it’s all because they’ve embraced ketogenic diets and “forsaken” fiber.
If this sounds like nonsense, that’s because it is.
Are millions of keto dieters suffering from bloating and constipation? I can find no evidence of this.
Is fiber necessary to prevent bloating and constipation? It’s complicated. I’ll explain later. But probably not.
Does the ketogenic diet necessarily exclude fiber? Not at all.
Are ketogenic diets as commonly practiced low in fiber? No.
What Is “Bloat” Anyway?
There are two things that people refer to as bloat: constipation and abdominal distension.
Constipation has different components. It’s being unable to make a satisfying bowel movement. It’s also feeling like you have to poop but are unable to. It’s being able to poop only a little bit. It’s struggling on the toilet bowl. Mostly, it’s being unhappy with your performance on the toilet.
Abdominal distension also can be different things. It might be trapped gas. It might be feeling “heavy” or “full.” It might mean your pants don’t fit after eating.
So, “bloating” can be any or all of these. You can pass hard small stools and feel like you’re bloated. You can poop just fine but have a lot of gas and feel like you’re bloated. You can spend hours on the toilet with not much to show for your effort and be bloated. So “Keto bloat” is difficult to pin down. That makes it easy to make claims and hard to disprove.
Let’s see how frequent bloating and constipation occurs in the ketogenic diet literature.
What Does Research Say About Constipation?
In a study of children with epilepsy placed on an olive oil-based ketogenic diet, about 25% of the subjects experienced constipation. So, was ketosis slowing them down? Not exactly. Those who experienced constipation were actually less likely to be in ketosis. Constipation went up as ketone readings went down, and epilepsy symptoms returned. Constipation improved as ketone readings went up and epilepsy symptoms subsided.
In adults with epilepsy on a ketogenic diet, constipation occurred in just 9% of patients. The authors note that this rate is lower than some other ketogenic studies and attribute the difference to “the heavy focus on importance of fiber from nutrient dense (fiber rich) vegetables, nuts, and seeds.” Note that they weren’t getting fiber from pills and powders. They were eating nutrient-dense foods that just so happened to contain fiber.
Another ten-year study compared the classical ketogenic diet, MCT oil-based ketogenic diet, and modified Atkins keto diet. They were all equally effective at reducing epilepsy symptoms in children, but the occurrence of constipation varied greatly. It was most common in the classic keto diet and medium chain triglyceride-based diet, both of which restrict protein. In the modified Atkins diet, which does not restrict protein, constipation was much rarer. Another study on the modified Atkins diet had similar results, with just 2 of 26 subjects reporting constipation.
Constipation does seem to be a common occurrence. However, the majority of keto diet studies are in epileptic populations following very strict clinical Keto diets. The extreme nature of these therapeutic ketogenic diets—extreme protein (7% of calories) and carbohydrate restriction—makes them an imperfect representation of how most people are eating Keto. And in studies of less-extreme, more realistic versions of the diet, such as modified Atkins (which allows more protein) or the version with “heavy focus” on vegetables, nuts, and seeds, constipation occurs at a much lower rate.
What Does Research Say About Bloating?
The only instance of something approximating bloating in the ketogenic diet literature occurred in studies using medium chain triglyceride-based diets. These are ones that use huge amounts of MCT oil to increase production of ketone bodies. It works great for curbing epilepsy symptoms, but it can also cause cramping, diarrhea, and abdominal pain. That’s not bloating per se. It’s literally the closest I could find.
Causes Of Bloating While Keto?
Okay, say you are dealing with constipation or bloating on a keto diet. What could be going on?
Not Enough Food
Constipation is often a consequence of low energy status. Everything that happens in the body requires energy, and if energy levels are low or energy availability is poor, basic functions will suffer. Bowel movements are no exception. The muscles and other tissues responsible for moving things along your digestive tract use energy. If you aren’t providing adequate amounts of energy, you’re depriving your tissues of the ATP they need to work best and sending your body a signal of scarcity which will only depress energy expenditure even more.
Low carb diets in general and keto diets in particular are very good at causing inadvertent calorie reduction. Great for fat loss, but some people take it overboard and go too far. I’m talking 800-1000 calories a day on top of CrossFit. That’s a recipe for disaster.
Water and Mineral Loss
When you go Keto for the first time, you shed tons of water. For every gram of glycogen you lose, you drop 3-4 grams of water. You also lose sodium and potassium with the water, and you need extra magnesium to regulate your sodium and potassium levels.
The water content of stool is what gives it that smooth texture we all desire. If you’re dehydrated, even mildly, you’ll have less water available for your bowel movements and be more likely to suffer from constipation.
Drink a big glass of salty water with lemon juice in the morning and sip on salty broth throughout the day. Zucchini is a great source of potassium, as is avocado.
Also, if you’re going to eat more fiber, you need to increase water intake for it to work.
Too Much or Too Little Fiber
The relationship between fiber and constipation is mixed. Some interventions do seem to help. Psyllium husk and flaxseed have both been shown to improve constipation. Galactooligosaccharides, a class of prebiotic fiber, improve idiopathic constipation. And inulin, another prebiotic fiber, improves bowel function and stool consistency in patients with constipation.
But there’s also evidence that more fiber can make the problem worse. In one 2012 study, patients with idiopathic constipation—constipation without apparent physiological or physical causes—had to remove fiber entirely to get pooping again. Those who kept eating a bit or a lot of it continued to have trouble evacuating. The more fiber they ate, the worse their constipation (and bloating) remained. Another review found mixed evidence; some people get less bloating and constipation with more fiber, others get less bloating and constipation with less fiber.
Personally, my toilet performance is stellar with or without a constant intake of voluminous levels of plant matter. Most days I eat a good amount—Big Ass Salads, broccoli, sautéed greens, berries—but on the days I don’t, I don’t notice any difference. I’m suspicious of the widespread calls for bowel-rending levels of fiber as the universal panacea for all things toilet, and I’m also suspicious of the people who claim fiber is unnecessary or even harmful.
Fiber helps some people and hampers others. There’s no one-size-fits-all with fiber, especially since there are many different types of fiber.
Too Many Sugar Substitutes
I get it. There are some interesting candies out there that cater to the Keto set and use various sugar alcohols—non-alcoholic, low-or-no calorie versions of sugar—artificial sweeteners, and fibers to recreate popular treats. It’s fun to eat an entire chocolate bar that tastes pretty close to the real thing and get just a few net carbs. But that’s a lot of fermentable substrate your gut bugs are more than happy to turn to gas.
If you want the opposite problem, you can always turn to Haribo sugar-free gummy bears.
FODMAPs stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols—the carbohydrates in plants that our gut bacteria usually mop up. Most people have gut biomes that can handle FODMAPs; indeed, most people derive beneficial short chain fatty acids from their fermentation. But some people’s gut biomes produce too much fermentation when they encounter FODMAPs. Fermentation begets hydrogen gas, which gathers in the gut and causes great distress. Common complaints of the FODMAP intolerant are bloating, stomach pain, and visits to the toilet that are either unproductive or way too productive—all of which fall into the bloating category.
The myth is that Keto people are eating salami and cream cheese for every meal. The reality is that many people go Primal or Keto and find they’re eating way more vegetables than they ever have before. These are great developments, usually, but if you’re intolerant of FODMAP fibers, you may worsen the bloating.
What Can You Do?
Eat enough protein. Most people can get away with eating 15-25% of their calories from protein and still stay in ketosis. Most people can eat even more protein and still get most of the benefits of fat-adaptation. The keto studies which had the lowest rates of constipation were far more tolerant of higher protein intakes.
Eat FODMAPs unless you’re intolerant. Most people can eat FODMAPs. In most people, FODMAPs improve gut health and reduce constipation and bloating. But if your gut blows up after a few bites of broccoli or asparagus, consult the FODMAPs list and try a quick FODMAP elimination diet.
Make sure you’re truly constipated. Your stool volume and frequency of toilet visits will decline on a normal ketogenic diet because there’s less “waste.” Make sure you’re not misinterpreting that as constipation or bloating. If there’s less poop, there’s less poop. If there’s more poop but it’s just not coming, and you have to go but can’t, that’s when you have an issue.
Experiment with fiber. Fiber clearly has a relationship to bloating and constipation. You just have to figure out what that looks like in your diet.
- If you’re bloated and constipated on a high-plant Keto Diet, eat fewer plants.
- If you’re bloated and constipated on a low-plant Keto Diet, try eating more plants. If that doesn’t help, go zero-plant.
- If you’re bloated and constipated on a zero-plant Keto Diet, try eating more plants. .
We all have to find our sweet spot.
So, to sum up, “keto bloat” is mostly a myth. There’s a glimmer of truth there, but it’s highly exaggerated. Constipation is common on the most restrictive clinical keto diets, while eating fiber from whole plant foods, being less restrictive with protein, and making sure you’re drinking enough water and eating enough calories and electrolytes seems to avoid the worst of it.
What’s been your experience with bloating and constipation? How have you handled it?
Ho KS, Tan CY, Mohd daud MA, Seow-choen F. Stopping or reducing dietary fiber intake reduces constipation and its associated symptoms. World J Gastroenterol. 2012;18(33):4593-6.
Müller-lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and misconceptions about chronic constipation. Am J Gastroenterol. 2005;100(1):232-42.
Guzel O, Uysal U, Arslan N. Efficacy and tolerability of olive oil-based ketogenic diet in children with drug-resistant epilepsy: A single center experience from Turkey. Eur J Paediatr Neurol. 2019;23(1):143-151.
Roehl K, Falco-walter J, Ouyang B, Balabanov A. Modified ketogenic diets in adults with refractory epilepsy: Efficacious improvements in seizure frequency, seizure severity, and quality of life. Epilepsy Behav. 2019;
Liu YM. Medium-chain triglyceride (MCT) ketogenic therapy. Epilepsia. 2008;49 Suppl 8:33-6.
Arnaud MJ. Mild dehydration: a risk factor of constipation?. Eur J Clin Nutr. 2003;57 Suppl 2:S88-95.
Noureddin S, Mohsen J, Payman A. Effects of psyllium vs. placebo on constipation, weight, glycemia, and lipids: A randomized trial in patients with type 2 diabetes and chronic constipation. Complement Ther Med. 2018;40:1-7.
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I have a confession to make: I, Mark Sisson, suffer from keto crotch.
It’s embarrassing, really. I thought maybe it was just the change in climate moving from Malibu to Miami—the humidity, the heat, the fact that I’m paddling and swimming more often now. There’s a whole lot of moisture down there. Perpetual steaminess.
But then I met up with my writing partner and good pal Brad Kearns, who’s been working with me on my upcoming book. Brad lives in Northern California, which is far from hot or humid right now. He’s also a staunch keto guy most of the time, and, well, let’s just say I could smell him before I could see him. We met up at a coffee shop and cleared out everyone in a fifteen foot radius. We sampled a new exogenous ketone product he’s been trying and not one, not two, but three separate individuals approached to inquire if we were salmon fishermen.
Okay, let’s get serious. Does “keto crotch” really exist? And, if it does, what can you do to prevent it?
I’m writing this not because of overwhelming demand from loyal followers of the Keto Reset plan. In fact, I hadn’t ever heard of “keto crotch” before last week. There’s a good chance almost no one heard of it before March 2019, if Google Trend data for “keto crotch” searches is any indication. I’m writing this post because the barrage of news articles, Twitter hashtag campaigns, and extremely serious warnings from people with lots of acronyms after their name has led people to ask me if it’s a legitimate phenomenon. A few acquaintances have brought it up in social situations. Our marketing director found herself fielding keto crotch questions at a dinner for Expo West last week.
So, are women following a ketogenic diet experiencing an epidemic of stinky vaginas?
Is Keto Crotch Even Physiologically Plausible?
Vaginal odor does change. It fluctuates naturally, and sometimes it can get worse. The most common cause of unpleasant changes to vaginal odor is bacterial vaginosis, which occurs when something upsets the balance between the beneficial lactobacilli bacteria that normally live in the vagina and pathogenic bacteria. What can upset the balance?
The vagina is supposed to be an acidic environment; that’s how the healthy lactobacilli thrive. If something upsets that pH balance, tilting it toward alkalinity, unhealthy bacteria gain a foothold and become predominant, and begin producing unpleasant-smelling amines like putrescine, tyramine, and cadaverine. This is bacterial vaginosis. As it turns out, the lactobacilli bacteria normally present in the vagina are instrumental in maintaining an acidic pH. They consume glycogen, spit out lactic acid, and exert antimicrobial and antifungal effects that block common vaginal pathogens like candida, e. coli, and gardnerella from taking hold and causing trouble.
The interaction between diet and vaginal biome is understudied. To my knowledge, there exist no direct controlled trials that address the issue. It’d be great to have a study take a cohort of women, split them up into different dietary groups, and follow them for a year, tracking their vaginal pH and bacterial levels. Alas, we do not.
We do have a study that provides a hint. In 2011, researchers looked for correlations between dietary patterns and bacterial vaginosis in a cohort of nearly 2000 non-pregnant mostly African-American women aged 15-44. While there probably weren’t many keto dieters, and the diets as a whole were of the standard American variety, glycemic load—which basically boils down to carb load—was the strongest predictor of bacterial vaginosis. Other markers of food quality, like a person’s adherence to “healthy eating guidelines,” initially seemed to reduce the chance of bacterial vaginosis, but those relationships were almost abolished after controlling for other factors. Only glycemic load remained highly significant.
This connection between dietary glycemic load and bacterial vaginosis starts looking more causal when you realize that diabetes—a disease where one’s “glycemic load” is perpetually elevated and exaggerated—is another risk factor for bacterial vaginosis.
There’s also a 2007 study that found “high” intakes of dietary fat, particularly saturated and monounsaturated fat, were a significant predictor of bacterial vaginosis. In this study, “high fat” meant around 39% of energy from fat. That leaves 61% of energy from carbohydrate and protein, the kind of “high-fat, high-carb” Standard American No-Man’s-Land that’s landed the country in the current metabolic predicament. High-fat intakes in the presence of high-carb intakes may very well be bad for your vagina, but it says nothing about the likelihood of keto crotch.
At any rate, neither study was a controlled trial, so we can’t say anything about causality.
What about a yeast infection? The most common offender is candida, which usually favors sugar for fuel, but there’s also evidence that it can metabolize ketones. Could keto make a latent yeast infection worse and lead to smelly “keto crotch”?
Perhaps keto can make candida worse (that’s for another day), but that’s not the cause of “keto crotch.” Candida vagina infections don’t smell very much, if at all, and they certainly don’t smell “fishy.” That’s only caused by bacteria and the aforementioned amines they can produce.
Free glycogen levels in vaginal fluid are a strong predictor of bacterial vaginosis. If ample glycogen is available, the good lactic acid bacteria have plenty of food and produce plenty of lactic acid to maintain the acidic pH conducive to vaginal health. If inadequate glycogen is present, the lactic acid bacteria have less food and produce less lactic acid, increasing the chances of the pH tilting toward alkalinity. An alkaline vagina is a vagina where pathogenic bacteria—the ones that produce stinky amines—can establish themselves.
The question then is if ketogenic diets lower free glycogen in the vaginal fluid. That’s a fair question. I wasn’t able to find any solid answers. I guess “ketosis effect on vaginal glycogen” isn’t the most lucrative avenue of scientific inquiry.
Should I Worry?
Even assuming this is a real phenomenon, it’s a rare one. The vast, vast majority of people following a ketogenic diet aren’t coming down with keto crotch. Other than a few Reddit posts from the past 5 years, I haven’t seen anyone at all in our neck of the woods complain.
Maybe people doing Primal keto are eating more nutrient-dense ketogenic diets than people doing conventional (or caricature) keto. Salads, steaks, eggs, and lots of non-starchy veggies are a great way to stay keto and obtain micronutrients. And there are links between micronutrient status and bacterial vaginosis. The most common relevant deficiencies include vitamin D (correcting the deficiency can cure the vaginosis) and folate. Hard to get adequate folate if your diet is based on salami and cream cheese.
We also know that the health of your skin biome tracks closely with that of your gut, and that eating plenty of non-starchy veggies, fermented foods (yogurt, kefir, sauerkraut, kimchi, etc), and colorful produce can provide prebiotic fiber, prebiotic polyphenols, and probiotic bacteria that nourish your gut biome. If the vaginal biome is also connected to the gut biome (and it is), tending to the latter should also have positive effects on the former.
The Primal brand of keto tends to emphasize micronutrients and gut health a bit more than some other types of keto I see floating around. If—and it’s a very big “if”—keto crotch is legit, that may explain some of the discrepancy.
Finally, be sure to check out this very interesting Twitter thread where the author lays out his suspicions that the whole “keto crotch” phenomenon might be a manufactured stunt designed to vilify the ascendant ketogenic diet. Nothing definitive, but it’s certainly food for thought.
If You’re Concerned…
Okay. Say you’ve recently gone keto and your vagina is smellier than usual. (And you’ve ruled out other, more obvious potential causes like changes in soaps, etc.) It’s hard to ignore, and I wouldn’t want you to. What can you do?
- Confirm that you have bacterial vaginosis. Seriously, get it checked out.
- Make sure you’re getting enough folate and vitamin D. Supplement if need be.
- Eat prebiotics and probiotics. Fermented food and/or a good probiotic supplement.
- Try a carb refeed. If ketosis depletes vaginal glycogen and increases pH, the occasional carb refeed could restore glycogen by 30-50 grams and should do the trick. Note that this is entirely theoretical; I’m not saying it’s a “problem” on keto.
- Hang out in the keto zone. I’ve written about the keto zone—that metabolic state where you’ve reached full keto and fat-adaptation and find yourself shifting in and out of ketosis as you please due to increased metabolic flexibility. A few carbs here, a fasting day there, a few more days of keto. Again, if full keto is theoretically depleting vaginal glycogen, maybe relaxing your restrictions will solve the issue while maintaining your fat adaptation. This is actually where I hang out most of the time.
That’s it for today, folks. Do you have “keto crotch”? Do you know anyone who does? Or did your vaginal health improve on keto? I’m curious to hear what everyone’s experiences have been, so don’t be shy.
Take care and be well.
Thoma ME, Klebanoff MA, Rovner AJ, et al. Bacterial vaginosis is associated with variation in dietary indices. J Nutr. 2011;141(9):1698-704.
Kalra B, Kalra S. Vulvovaginitis and diabetes. J Pak Med Assoc. 2017;67(1):143-145.
Taheri M, Baheiraei A, Foroushani AR, Nikmanesh B, Modarres M. Treatment of vitamin D deficiency is an effective method in the elimination of asymptomatic bacterial vaginosis: A placebo-controlled randomized clinical trial. Indian J Med Res. 2015;141(6):799-806.
Dunlop AL, Taylor RN, Tangpricha V, Fortunato S, Menon R. Maternal vitamin D, folate, and polyunsaturated fatty acid status and bacterial vaginosis during pregnancy. Infect Dis Obstet Gynecol. 2011;2011:216217.
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The relationship between stress and carbohydrates is confusing, with seemingly contradictory arguments bouncing around the online health sphere.
There are those who say high-carb diets cause stress, and that eating more fat and fewer carbs is the solution.
There are those who say high-fat diets increase stress and eating carbs ameliorates it.
Who’s right? They can’t both be right, can they?
You’d be surprised.
Let’s dig into four common carb questions and assertions.
“Stress Increases Carb Cravings.”
This is well-established. You have a terrible day at the office, your kids have appointments twenty miles apart within fifteen minutes of each other, the traffic is backed up to your driveway, you’re late for work, the dog needs a walk, you haven’t even thought about what to make for dinner, you slept four hours last night—it adds up. People deal with a lot. And in that moment, a carbohydrate-based snack really does seem to take the edge off.
Across millions of years of hominid evolution, the human stress response developed in the context of real-world, short-term, and infrequent but intense stressors: battles, hunts, freak injuries, dangerous animal encounters, interpersonal conflicts. These were situations that demanded heightened senses, available fuel, and a rapid heart rate to deliver everything to the tissues that needed to move and act. It makes perfect sense for your body to pump out adrenaline to increase fat burning and glucose in the blood—you need that fuel to deal with the situation. It also makes sense for your body to follow that up with a blast of cortisol, which makes you crave high-carb junk food to replace the fuel you utilized. The problem is that our modern stressors are too frequent, they aren’t physically demanding, we aren’t utilizing the fuel we mobilize, and we have no real need for the carb cravings that come after.
What happens when we eat too many carbs that we never actually needed?
We get fat. Cellular energy supply becomes overloaded, impairing our mitochondria’s ability to process energy efficiently. This degrades metabolic flexibility—the ability to switch between different fuel sources—preventing us from burning the fat on our bodies in between meals. We become reliant on those carbs, and when we don’t get them fast enough, our bodies perceive that as a major stressor.
So while giving in to carb cravings can reduce stress in the short-term, it sets us up for longer-term, more chronic stress.
“What About Gluconeogenesis? Isn’t That a Stress Response?”
It can be.
A primary goal of cortisol is to increase glucose availability. It does this through multiple avenues. One I just mentioned is to increase carb cravings. Another is to make you insulin resistant, thereby preventing insulin from sucking up blood glucose. Gluconeogenesis—the creation of glucose from amino acids and other substrates—is another.
If you’re a sugar-burner, stressful situations will increase carb cravings, induce gluconeogenesis, and may even make you insulin resistant. If you’re fat-adapted, the story shifts.
A fat-adapted person will have ketones and fatty acids available to provide energy in between meals. A fat-adapted person will have ketones and fatty acids available to provide energy in stressful situations. A fat-adapted person will be able to utilize those ketones and fatty acids during stressful situations—their mitochondria will literally be primed to utilize those fuels, not just glucose. A fat-adapted person is less likely to perceive carbohydrate shortages as stress shortages because they’ve got all this other fuel available to burn.
This adaptation doesn’t happen overnight. If your diet is low-carb or keto, but your body is still reliant on sugar, you will perceive reduced carb availability as a stressor. That’s one of the hallmarks of the keto flu, and it’s one reason why some people have extended keto flu—their bodies are still expecting and demanding glucose.
Some people never get over the carb cravings; they never fully adapt. This is the subset of the population that doesn’t function or perform well on a long-term ketogenic diet. The cause is unknown, at least for now (I suspect it has to do with recent ancestry and genetic proclivities), but what matters is that these people exist. For them, a long-term keto or very low carb diet approach will probably always be stressful. But even in these folks, spending some time in ketosis—through short term low-carb eating, intermittent fasting, or even extended low-level endurance activity that primarily burns fat—is a good idea that will reduce stress and improve overall resilience.
“But Carbs Make Exercise Less Stressful!”
Exercise is stressful to begin with. But then you adapt to the stress and overcome it—and end up stronger, fitter, and faster than before. Without the stress, working out doesn’t work. A legitimate method for increasing your work capacity is to train-low (carb), race-high (carb). Athletes have been doing this for decades—training in a low-carb state to get better at performing without ample muscle glycogen, then going into a race with full glycogen reserves and the ability to perform without glycogen. Exercising in that low-glycogen state is stressful, but that’s the whole point. It makes them better, stronger, faster, and it conserves glycogen for when they really need it.
If you consistently perform glucose-intensive high-intensity anaerobic activity for extended periods of time—CrossFit style WODs done 3-5 times per week, for example—you will run up a glucose debt and should replenish some of the carbohydrates you expend or risk cortisol spikes. Fat-adaptation can improve your tolerance of anaerobic activity in a low-glucose state, but there’s a breaking point, a physiological limit.
Eat the carbs you earn. This is a subtle point I don’t often see made. The reverse is widely understood—don’t eat the carbs you don’t earn—because millions of obese and overweight people do that every day. It’s a big reason why we’re so overweight. But if you fail to eat the carbs you earn through intense, protracted physical activity, you’re creating an undeniable glycogen deficiency that your body may perceive as a stressor. It may turn out that fully fat- and keto-adapted athletes can perform intense medium-to-long-term activities at high levels, and there’s some indication that this is the case, but for the time being it appears that eating the carbs you earn can stave off the stress.
“Low-Carb Diets Are Stressful For Women.”
There’s a glimmer of truth here. Allow me to explain.
Women are inherently more sensitive to caloric fluctuations than men…on average. The reason is sheer biology. Human evolution is concerned with fertility and reproduction. Can you produce, foster, and support viable offspring? Awesome. Natural selection deems you fit.
To fulfill their biological role, men have to produce sperm. They can do so almost indefinitely. They don’t run out; they just make more. If a batch is damaged due to poor lifestyle or dietary choices, there’s more on the way. After a man gets someone pregnant, his biological involvement with the growing baby is done. What or when he eats has no impact on the survival of the growing baby.
To fulfill theirs, women have a finite number of eggs, or “chances.” Once an egg is gone, there’s no replacing it.
And so the body seeks to inculcate the egg from environmental insults.
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 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. Even if you’re never going to have kids, your body is still wired to protect against these caloric fluctuations.
Where do carbs come in?
One’s carbohydrate consumption is uniquely hewed to our sense of caloric sufficiency. If carbs are plentiful, your body perceives that as a signal of environmental plenty: the weather is good, the plants are producing, the trees are bearing fruit, the men are bringing back lots of honey. Life is good. It’s the perfect time to get pregnant. Above all other macronutrients, carbohydrate consumption increases the short-term expression of leptin, a satiety hormone that signals the presence of incoming calories, caloric sufficiency, and environmental plenty.
There’s also the issue of extreme satiety. Low-carb diets often become low-calorie diets without you even trying. That’s why they work so well for fat loss, by inadvertently reducing the amount of food you eat and increasing satiety. But for some women, especially those at or approaching their ideal weight, going too low in calories can increase stress.
Are you unable to access your own body fat in between meals for energy? Then you’ll be a ball of stress unless you can get those Jolly Ranchers unwrapped quickly enough. It’ll be a constant battle. And yeah, if you keep pumping yourself full of carbs to keep your blood glucose topped off, you’ll keep stress at bay—but you’ll always be teetering on that precipice.
Are you exercising? Then you should strike a balance between gaining the adaptive benefits of training in a low-carbohydrate state and eating the carbs you earn.
Are you a woman? Then you’re probably more sensitive to diet-induced stress and may benefit from occasional carbohydrate refeeds. You should watch out for excessive satiety on ketogenic diets, which is great for fat loss but can lead to stress issues down the line if calories get too low.
The relationship between carbohydrates and stress isn’t exactly straightforward, but it is navigable. Hopefully after today you have a better idea of where you stand in the relationship.
What’s been your experience with stress and carbohydrates? Has your tolerance for stress gone up or down since going low-carb or keto? Thanks for stopping in today.
Mcallister MJ, Webb HE, Tidwell DK, et al. Exogenous Carbohydrate Reduces Cortisol Response from Combined Mental and Physical Stress. Int J Sports Med. 2016;37(14):1159-1165.
Dirlewanger M, Di vetta V, Guenat E, et al. Effects of short-term carbohydrate or fat overfeeding on energy expenditure and plasma leptin concentrations in healthy female subjects. Int J Obes Relat Metab Disord. 2000;24(11):1413-8.
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We get lots of questions about how a ketogenic diet works in the context of exercise: Is it possible to maintain one’s fitness (strength, endurance, performance) and also drop one’s carb intake to ketogenic levels? Is it advisable? Will it help me lose weight faster?
Mark already addressed some of these topics, but it’s clear that many people still feel uncertain about how to pair a keto diet with their current workout routine.
Rather than write a single behemoth post, I’m going to tackle this in two parts. For today, let me talk keto and cardio, specifically how keto works for the average fitness enthusiast who thinks more in terms of general exercise. In a couple weeks I’ll follow up with a post on keto for runners and other endurance types who tend to focus on training programs and racing.
So, keto and cardio… This is for people who like to attend group fitness classes, or go out for jogs or spins on the bike, or do a mix of low heart rate exercise with occasional bouts of HIIT. (This is a problem with the term “cardio”—it can mean so many things.)
You probably already know Mark’s stance on cardio: avoid chronic cardio exercise patterns. The Primal Blueprint approach to exercise comprises lots of everyday movement, lifting heavy things, and occasionally going all out. If you simply must do cardio, most of these sessions should be conducted at an aerobic heart rate not higher than 180-age, as detailed in the Primal Endurance book. So, with the caveat that cardio exercise in the traditional sense of slogging away on an elliptical machine or treadmill doesn’t jibe with the Primal Blueprint approach, let’s get to some frequently asked questions.
Will My Workouts Suffer When I Go Keto?
This is a common concern because some people do report that they feel sluggish when they first go keto. And yes, you might feel like your performance in the gym (cardio, strength, HIIT—all of it) takes a hit in the first few weeks of keto. Rest assured that this is a temporary dip as your body becomes efficient at using fat and ketones for energy in the absence of incoming carbs (glucose). It’s a learning process for your body, so to speak.
The more glycolytic your workouts, the more you are going to notice this. Prolonged, difficult workouts that fall into the category of chronic cardio or “black hole” sessions are especially likely to suffer.
To help mitigate temporary performance decrements during the transition to keto:
- Dial back the intensity and/or frequency of your workouts for a few weeks. Trade some of your more intense cardio (and strength) sessions for walks, yoga or Pilates, or other gentle forms of movement.
- Mind your electrolytes. If you are feeling weak or lightheaded, if you get a headache, or you just feel “off,” this is likely due to electrolyte imbalance. Try adding ¼ – ½ teaspoon of salt to a glass of water with lemon juice and see if that helps. You want to make sure you are getting 4.5 grams of sodium, 300-400 mg of magnesium, and 1-2 grams of potassium each day on top of your normal food.
- While your body is making the switch, give it plenty of fuel. Consume extra fat and eat plenty of calories. If fat loss is a goal, you can adjust your macros and calories as needed once you are feeling in the groove with keto.
- Tough it out. Don’t cave and add carbs in the first few weeks (see the next point). Know that this is temporary, and you should be back to normal within three to six weeks.
Do I Need To Add Back Carbs To Fuel My Workouts?
During the first few weeks of starting keto, you should not add back carbs. It is important to create a low-glucose, low-insulin environment to promote ketogenesis and the adaptations that accompany a ketogenic state. If your workouts are too hard right now, the correct answer is to change your workouts, not to increase your carbs.
After you have done a dedicated period of a minimum three weeks of strict keto—six or more is even better—you should be feeling better during your workouts if you are not engaging in prolonged, chronic cardio activities. (It might take longer to adapt to longer endurance training, as we will discuss in the next installment.) At this point you have some options:
One, you can continue in strict ketosis (less than 50 grams of carb per day) as long as you are feeling good.
Two, you can start experimenting with eating carbs strategically before your workouts. This is known as a targeted keto approach. There are various ways of implementing this, but the basic formula is that you would ingest 25-30 grams of glucose or dextrose (not fructose) about half an hour before high-intensity workouts to replenish muscle glycogen.
There are a few caveats here. First, most sources of glucose/dextrose are not Primal (think hard candy, gels). Probably the closest is pure maple syrup, but that also delivers a hit of fructose. If you are a Primal purist, you will have to decide if this is a compromise you want to make. Second, people tend to overestimate the degree to which they are actually low on glycogen and how much it matters. It is a common misconception that once you go keto you have “no glycogen.” While muscle glycogen stores are reduced, your tanks are probably still at least 50% full, and perhaps on par with non-ketogenic folks if you have been keto for a long time. Furthermore, the average low-to-medium intensity cardio session isn’t truly depleting glycogen. Remember, the point of becoming fat- and keto-adapted is that you burn predominantly fat and ketones at these lower intensities, sparing glycogen. You have to go hard and/or long to really burn through your muscle glycogen stores. Thus, you should target pre-workout carbs only before truly high-intensity sessions.
Instead of adding simple carbs before workouts, another option if you feel like you need more carbs is to add back nutrient-dense carbs after workouts, when insulin sensitivity is increased. This might make sense if you feel like your ability to recover between workouts is lagging, or you want to recover quickly because you have back-to-back hard sessions planned. In either case—adding carbs before or after exercise—the amount you add should be proportional to the difficulty (intensity) of the workout. You don’t need to carb up for your yin yoga class, for example.
Lastly, if you are feeling underpowered during exercise, instead of adding back carbs you can experiment with adding more protein and/or fat. Some people report good success with “protein ups” timed around heavier workout days.
Will Adding Keto to My Cardio Routine Help Me Lose Weight?
Maybe. It’s a common refrain that “abs are built in the kitchen,” meaning that your food plays a bigger role in fat loss than does your exercise. This isn’t to say exercise is unimportant; it does matter. A caloric deficit is necessary to lose body fat, and exercise is one way to create a caloric deficit. However, this can also backfire if your exercise routine leaves you hungrier, so you unintentionally overeat calories due to increased hunger and cravings. Ketones have known appetite suppressing effects, so a ketogenic diet might help counteract any increased hunger that comes with exercise.
That said, I think the root of this question is the fact that ketosis is a fat-burning state, and so the logic goes that if you are metabolizing fat for energy, you will automatically shrink your body fat stores. Moreover, if you add keto and cardio together, especially if you are exercising in the so-called “fat-burning zone,” you will lose more fat than either alone. Right? Not necessarily. The fat you burn can come from your adipose tissue or from your plate. If you are eating an excess of fat calories relative to your daily caloric needs, you still won’t lose body fat.
We know that for body recomposition, the best bang for your buck comes from a combo of resistance training and HIIT. Cardio exercise still has many benefits for physical and mental health, and of course a lot of people simply enjoy their cardio; but you shouldn’t be putting all your eggs in the cardio basket if fat loss is your goal. All else being equal, though, it certainly can’t hurt to upregulate your body’s ability to use fat for energy.
- When first starting out with keto, follow the recommendations laid out in The Keto Reset Diet, and be strict for at least three weeks.
- If you are struggling in your cardio workouts during this period, don’t add back carbs! Dial back your workouts, add calories (via fat or protein), or both.
- Once you believe you are keto-adapted, then you can start to experiment with targeted carbs and/or carb ups if you so choose.
- No matter your diet, avoid chronic cardio exercise patterns that increase stress and your body’s demand for glucose.
- Check out this post for additional tips for exercising while keto.
Thanks, everyone. Questions, comments? Share them below, and have a good week.
Koeslag T, Noakes T, Sloan A. Post-exercise ketosis. J Physiol 1980;301;79-90.
Malhotra A, Noakes T, Phinney S. It is time to bust the myth of physical inactivity and obesity: you cannot outrun a bad diet. Br J Sports Med 2015;49:967-968.
Matoulek M, Svobodova S, Vetrovska R, Stranska Z, Svacina S. Post-exercise changes of beta hydroxybutyrate as a predictor of weight changes. Physiol Res. 2014;63 Suppl 2:S321-5.
Newman JC, Verdin E. ?-hydroxybutyrate: much more than a metabolite. Diabetes Res Clin Pract. 2014;106(2):173-81.
Sleiman SF, Henry J, Al-Haddad R, et al. Exercise promotes the expression of brain derived neurotrophic factor (BDNF) through the action of the ketone body ?-hydroxybutyrate. Elife. 2016;5:e15092.
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Pot pies—like sloppy joes—are a comfort food classic that feeds our nostalgia as well as appetite. Meat and veggies in a creamy sauce that’s topped with a crunchy topping…what’s not to love? It might seem, however, that pot pie isn’t compatible with a Primal, let alone keto, plan. Au contraire. We’ve serving up a recipe today that turns that assumption on its head. Pot pie is no longer pie in the sky for the keto eater. Enjoy!
Time In the Kitchen: 40 minutes
For the Filling
- 4 slices of bacon
- 1 white or yellow onion, chopped
- 7 ounces/200 grams pre-cooked chicken (meat from approximately 3-4 chicken thighs)
- 1 carrot cut into cubes
- 1/2 cup chopped turnip
- 2-3 cups chicken stock or bone broth
- 2 tbsp arrowroot flour
In a large pan with lid, saute the bacon and onion over medium heat.
Add in the carrots and mushrooms. Cook through.
Add in chicken and cover the mixture with chicken stock.
In a separate pot, stir arrowroot with a drizzle of cold water.
Add the flour mixture to the chicken, carrots and mushroom. Add frozen peas and thyme. Lower heat and cook until the sauce thickens.
Remove from heat and distribute evenly in oven-safe bowls or ramekins.
For the Crust
- 1 1/4 cup almond flour
- 1/4 tsp salt
- 1/2 tsp baking powder
- 1 egg
- 4 tbsp ghee
Preheat oven to 350 ºF/175 °C.
Mix all dry ingredients together.
Mix the egg and the ghee in a separate bowl.
Combine the dry and the wet ingredients together. The dough should be moist like the dough for drop biscuits.
Spread the dough evenly on the ramekins filled with the chicken and vegetable filling.
Bake in the oven for 20-25 minutes until the crust is golden. Put under broiler for a very short time to brown the crust at the end if desired.
- Calories: 534
- Carbs: 14.75 grams
- Fat: 39 grams
- Protein: 29 grams
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We’ve all heard the story. Maybe we’ve even been the protagonist.
Person goes full keto. They lose a bunch of weight, normalize their pre-diabetic glucose numbers, resolve their high blood pressure readings, have more energy, feel great, and have nothing but high praise for the new way of eating.
Except for one thing, everything seems perfect: their cholesterol is sky-high. It throws a wrench into the whole operation, installs a raincloud over the procession, spoils their confidence.
“Could I be killing myself?”
“Are my health improvements just a mirage?”
In other words, are the apparent benefits of keto merely superficial if your cholesterol skyrockets?
The evidence is pretty clear that for the majority of adults who go keto, their cholesterol numbers improve.
In obese adults with type 2 diabetes, a ketogenic diet improved blood lipids and boosted fat loss compared to a low-calorie diet.
In lean, healthy adults without any weight to lose (and who didn’t lose any weight during the course of the diet), total cholesterol went up from 159 to 208 mg/dL and triglycerides fell from 107 to 79 mg/dL. A lipophobic doc might freak out at the rise in TC, but given that the triglycerides dropped, I bet the change reflects a rise in HDL and an overall positive, at worst-neutral effect.
Another study of lean adults with normal cholesterol numbers found that going keto improved their lipids, reducing triglycerides, increasing HDL, and leaving LDL unchanged. Those with small pattern B LDL particles (the “bad kind”) saw their LDL particle size increase, on average. All told, keto was beneficial.
But you aren’t everyone. You aren’t the average of a population. And, given the number of readers I have and the number of people trying a ketogenic diet, there are bound to be some people whose lipid profiles go in the other direction.
I don’t give medical advice here, and I always encourage people to partner with the physicians for health solutions. That said, let me share some thoughts on the keto-cholesterol question….
I’m not just talking about high total cholesterol or high LDL-C. I’m talking about what appears to be the real, legit risk factor for a cardiac event: elevated LDL particle number. According to experts like Dr. Peter Attia and Dr. Chris Masterjohn, atherosclerosis occurs when LDL particles infiltrate the endothelial lining of our arteries. Thus, it’s not high LDL cholesterol that increases the risk of atherosclerosis—LDL-C is the cholesterol found inside the particles— it’s a high number of LDL particles in circulation. The more LDL-P, the greater the chance of them becoming oxidized and infiltrating the arterial wall. There are many factors to consider, like oxidative stress, inflammation, and fatty acid composition of the LDL particles, but all else being equal, a greater number of LDL particles seems to increase the risk of a heart attack.
What Could Be Causing LDL Elevations On Keto?
I asked Dr. Cate Shanahan for her input on this topic, and she provided a beautiful explanation:
But when you stop eating so many carbs insulin politely steps aside, and your insulin levels plummet. Now your body fat can more easily and more often release its stores of fatty acids into your bloodstream.When your body fat releases stored fatty acids, any unused fatty acids quickly get picked up by the liver and packed into VLDL lipoprotein. VLDL is a precursor to LDL. So in reducing your insulin levels and increasing your body’s use of fat, you will raise your VLDL, LDL and total cholesterol. You are simply trafficking in fat more often now. And now, because your body stabilizes fat carrying lipoproteins with cholesterol, there is a need for more cholesterol in your blood. These are not bad consequences. They are in fact happy signs your diet is doing what its supposed to be doing.
If you’re actively losing weight, you will probably experience a rise in cholesterol. This is the transient hypercholesterolemia of major weight loss, and it’s a well-known phenomenon. Once your weight stabilizes, cholesterol should normalize—although to a lesser extent than other diets, given Dr. Cate Shanahan’s explanation of increased “trafficking in fat.”
Low Thyroid Function
The thyroid is a barometer for your energy status. If you have plentiful energy to spare, thyroid function is normal. If your body perceives low energy availability, thyroid function may down-regulate. Since the thyroid plays a big role in regulation of LDL receptor activity, its downregulation can lower LDL receptor sites. Fewer LDL-receptors clear LDL particles from the blood. Folks with genetic predispositions to heart disease often have low LDL receptor activity, causing elevated LDL particles. Folks with genetic variants that increase the activity and expression of LDL receptors have lower heart disease rates. Although genes often have different effects that may affect disease risk via other pathways, that’s pretty strong evidence that LDL receptor activity regulates, at least in part, one’s LDL-P and heart disease risk.
Read this post for maintaining thyroid function on keto, and check out Elle Russ’ Paleo Thyroid Solution for an even deeper, more thorough dive into thyroid health.
Eating Too Damn Much
Some keto people pride themselves on gorging. Some are doing it for a good cause—a quest to find the fabled metabolic advantage. Some are doing it to show off and for keto cred—look how much salami I can eat! Some are using keto to deal with unresolved issues with food itself.
Everything I say about doing keto presupposes that you are eating like a normal person. You’re eating as much as you need to fuel your brain and daily activities, fitness and performance goals. You’re leaving the table satiated, not stuffed. For most people, this happens without even trying. It’s why keto is so effective for weight loss.
Genes aren’t destiny, but they do modify and regulate our response to a given environmental input.
Some people are dietary cholesterol hyper responders. Unlike the majority of the population, they absorb tons of dietary cholesterol and do not down-regulate their endogenous production to accommodate. The result is an increase in cholesterol synthesis and absorption, leading to a spike in blood cholesterol.
Some people are sensitive to saturated fat. In response to it, they produce elevated numbers of LDL particles. If your keto diet is high in saturated fat and you have a genetic sensitivity to it, your cholesterol will probably skyrocket.
Some people have genes that reduce the activity of their LDL receptors. This will necessarily boost LDL particle numbers.
This topic—genetic variance and how it affects keto—could be an entirely separate post, so I’ll leave it at that (and probably come back to it in the future).
Too Much Butter
Huh? Too much butter, Sisson? Is such a thing even possible?
Maybe. Subjecting cream to the butter-making process strips it of something called milk fat globule membrane (MFGM). And when you compare equal amounts of dairy fat through either cream (with MFGM intact) or butter oil (with MFGM absent), you get very different metabolic effects. Those who ate 40 grams of dairy fat through butter oil saw their lipids worsen, including ApoB, a surrogate for LDL particle number. Those who ate 40 grams of dairy fat through cream saw their lipids unchanged, and in the case of ApoB even improve. That’s 4 tablespoons of butter compared to 4 ounces, or a half cup, of heavy cream.
Caveats apply here. The subjects weren’t eating a low-carb or ketogenic diet; they just added the butter or cream on top of their normal diet. But in keto people who are genetically susceptible, huge amounts of butter may be responsible for rising LDL-P.
I still love butter. It doesn’t affect my lipids like that. But your mileage may vary, and it’s something to think about if you’re in that situation.
So, What Can You Do If You See An Increase in LDL?
Start Chugging Soybean Oil
Kidding… It’s true that swapping out some of your animal fats for polyunsaturated seed oils will almost certainly lower your cholesterol levels. It does this by increasing LDL receptor activity, but, being far more unstable than other fats, omega-6 PUFAs also increase the tendency of the LDL particles to oxidize. And since oxidized LDL are the ones that end up wedging in the arterial walls and causing issues, loading up on PUFAs might not be the right path.
You know what just occurred to me? This is an aside, but maybe linoleic acid (the primary fatty acid in seed oils) up-regulates LDL-R activity because the body recognizes the inherent instability of linoleic acid-enriched LDL particles and wants to clear them out before they can cause trouble. I hope some researchers take this idea further.
Stop Being a Keto Caricature.
Half a package of cream cheese for a snack.
Dipping an entire stick of pepperoni into homemade alfredo sauce and calling it dinner.
I’m not saying cream cheese is bad. It’s great. Nor am I suggesting you never eat pepperoni, dipped in alfredo sauce or not. But the amounts are unreasonable. And turning those into regular meals is a bad idea. There’s no reason you can’t go keto while eating a hamburger patty or ribeye over a Big Ass Salad. Far more nutrients, far more micronutrients, and it tastes way better.
Maybe if you’re a nomadic horselord sweeping across Europe in the early Bronze Age, you need to eat an entire lamb intestine stuffed with marrow and organs, and you should wash it down with a quart of creamy mare milk. Such a meal would provide the calories you need to see your enemies driven before you and go great with the lamentations of their women. But you’re not a Yamnaya nomad. You’re you.
You probably don’t need that much food, that many calories, and that much fat—since there’s plenty of it on your body already, waiting to be liberated and converted into energy. Therein lies the beauty of keto. That’s what this is all about: Getting better at burning your own body fat.
Balance Your Fats
The overzealous and protracted drive to demonize all sources of saturated fat as evil has led to a vociferous backlash from the other direction. But just because the supposed experts got the saturated fat issue wrong doesn’t mean the opposite is true: That all the fat we eat should be as saturated as possible.
For one thing, eating nothing but saturated fat is very hard to do using whole foods. Very few animals exist in the world, past or present, with only saturated fat. The only exception I can recall is the coconut, a curious sort of beast that spends most of its time hanging from a tree impersonating a large hairy drupe. Your average slab of beef fat runs about 50% saturated fat, 45% monounsaturated fat, and 5% PUFA. That differs from cut to cut and depending on the diet of the animal, but not by much. It’s similar for other ruminants like bison and lamb. And the most prominent saturated fatty acid in ruminant fat is stearic acid, a fat that converts to monounsaturated oleic acid in the body and has an effect on cholesterol indistinguishable from MUFA or PUFA.
Or take the fatty acid composition of game meat—the type humans encountered and consumed for our entire history.
- African kudu (antelope family): 35% SFA, 24% MUFA, 39% PUFA
- African impala (antelope family): 51% SFA, 15% MUFA, 33% PUFA
- Elk: roughly 40% SFA, 30% MUFA, 30% PUFA
- Moose: roughly 33% SFA, 33% MUFA, 33% PUFA
I could go on, but you get the idea: Humans have been consuming a wide range of fatty acids for millennia. It probably makes sense to emulate that intake.
Once again, the folks whose cholesterol goes nuts on keto are outnumbered by those whose cholesterol improves. But if you’re one of the unlucky ones in the former category, try broadening your fatty acid intake (to, ahem, possibly include more nuts):
- Focus on monounsaturated fats and fat from meat, rather than isolated sources of saturated fat like butter and coconut oil. You probably don’t have to eliminate those fats. Just don’t make them the centerpiece of your diet.
- Eat more avocados, avocado oil, olives, olive oil, and mac nuts for monounsaturated fat. Salads are a great nutrient-dense way to incorporate high-MUFA foods.
- Eat more fish. A couple portions of farmed Atlantic salmon were enough to improve LDL-P in overweight men and women. And compared to plain keto, keto + omega-3s from fish has a superior effect on inflammation and metabolic health.
- Eat more kudu and impala (if you can get it). Sort of kidding. But really, eat them if you can.
They even have a version of keto called the Spanish ketogenic diet, which features a lot of extra virgin olive oil, olives, fish, and red wine. It works great and might be a good alternative for people whose cholesterol goes wild on saturated fat-heavy keto.
Are Traditional Lipid Markers Even Relevant for Keto Dieters?
Maybe, maybe not.
But be honest about it. You can’t oscillate between championing positive changes to blood lipids on a keto diet and pooh-poohing negative changes to blood lipids on a keto diet.
You can’t use positive changes to prove the efficacy and safety of the ketogenic diet, then turn around and claim that negative changes don’t count because keto dieters are understudied. What if those “positive” changes are actually negative in the context of a ketogenic metabolism? After all, keto dieters are largely understudied in both directions. If what’s unhealthy in a normal dieter might be healthy in a keto dieter, what’s healthy in a normal dieter may be unhealthy in a keto dieter.
I write these things as a strong proponent of spending a significant time in ketosis. As someone who frequently hangs out in a ketogenic state. As someone who wrote a book about keto and is writing another. But also as someone who insists on maintaining strict intellectual honesty and integrity.
We simply don’t know what very high cholesterol numbers mean in the subset of ketogenic dieters who experience them. I strongly suggest not being too flippant about them.
True: There aren’t any perfect studies examining the utility of conventional cardiovascular risk factors in people eating the type of keto diets you see in the ancestral health space. Maybe your elevated LDL particle number doesn’t mean what it means in the average overweight adult eating the Standard American Diet. Maybe your inflammation is low enough that the risk of atherosclerosis and oxidative modification of LDL is low. But I wouldn’t take that risk, not until we have more data.
What do you think, folks? How did keto affect your blood lipids? Did you make any changes, and if so, did they work? Thanks for stopping in today.
Note: This information isn’t intended as and shouldn’t be considered medical advice. Always consult your doctor in the management or treatment of any health issue.
Hussain TA, Mathew TC, Dashti AA, Asfar S, Al-zaid N, Dashti HM. Effect of low-calorie versus low-carbohydrate ketogenic diet in type 2 diabetes. Nutrition. 2012;28(10):1016-21.
Phinney SD, Tang AB, Waggoner CR, Tezanos-pinto RG, Davis PA. The transient hypercholesterolemia of major weight loss. Am J Clin Nutr. 1991;53(6):1404-10.
Phinney SD, Bistrian BR, Wolfe RR, Blackburn GL. The human metabolic response to chronic ketosis without caloric restriction: physical and biochemical adaptation. Metab Clin Exp. 1983;32(8):757-68.
Kleinveld HA, Naber AH, Stalenhoef AF, Demacker PN. Oxidation resistance, oxidation rate, and extent of oxidation of human low-density lipoprotein depend on the ratio of oleic acid content to linoleic acid content: studies in vitamin E deficient subjects. Free Radic Biol Med. 1993;15(3):273-80.
Rosqvist F, Smedman A, Lindmark-månsson H, et al. Potential role of milk fat globule membrane in modulating plasma lipoproteins, gene expression, and cholesterol metabolism in humans: a randomized study. Am J Clin Nutr. 2015;102(1):20-30.
Raatz SK, Johnson LK, Rosenberger TA, Picklo MJ. Twice weekly intake of farmed Atlantic salmon (Salmo salar) positively influences lipoprotein concentration and particle size in overweight men and women. Nutr Res. 2016;36(9):899-906.
De luis D, Domingo JC, Izaola O, Casanueva FF, Bellido D, Sajoux I. Effect of DHA supplementation in a very low-calorie ketogenic diet in the treatment of obesity: a randomized clinical trial. Endocrine. 2016;54(1):111-122.
Pérez-guisado J, Muñoz-serrano A. A pilot study of the Spanish Ketogenic Mediterranean Diet: an effective therapy for the metabolic syndrome. J Med Food. 2011;14(7-8):681-7.
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Question: “Can I eat fruit on a ketogenic diet?”
Answer: “Sure, if you want!”
I’m kidding, of course. I know why people ask this question. It’s because in the keto world fruit is a confusing, often contentious topic. You’ll sometimes see keto folks draw a hard line in the sand, saying that all fruits, or sometimes specific fruits, are “not allowed” on a ketogenic diet. I’ve written before about why I feel it’s inappropriate to label foods as “keto” or “not keto.” People need to consider their own goals, health, activity level, and food preferences when formulating their eating strategies.
Nevertheless, it’s true that it can be hard to figure out how to incorporate fruit into your keto diet. On the one hand, it’s “real” food: unprocessed, “whole,” and full of vitamins, minerals, fiber, and phytonutrients. It’s also Primal/paleo approved in moderation. On the other hand, the carbs in a typical serving of fruit can amount to a considerable chunk out of one’s daily carb allotment, especially for people who adhere to a very strict version of keto that only allows 20 to 30 grams of carbohydrate per day (as opposed to the Keto Reset Diet’s 50 gram per day suggestion).
So where does fruit fit for the average person following a Keto Reset Diet?
Keto People CAN Eat Carbs
Sometimes you’ll hear someone say that keto-ers can’t eat fruit because they “don’t eat carbs.” They really mean that keto folks don’t eat sugar, which is still a gross oversimplification because keto people absolutely do eat carbs. If you’re eating according to the Keto Reset Diet, you’ll start by aiming for 50 grams of carbohydrates per day—perhaps somewhat less if you are dealing with type 2 diabetes or metabolic syndrome—with some wiggle room if most of your carbs come from above-ground veggies and avocados.
From the point of view of the Keto Reset, we want you to choose your carb sources from among those included on the Primal Blueprint Food Pyramid. That means no grains or added sugars, but eating nutrient-dense vegetables and, yes, even some fruit if you wish.
What Fruits Are Best For Keto?
When picking the “best” fruits for keto, it comes down to how many carbs are in a serving. Higher carb fruits are going to be harder to incorporate into a keto diet while still allowing room for the liberal intake of vegetables and avocados encouraged in the Keto Reset.
The information below is taken from the Cronometer database. Make sure you pay attention to the serving size. I selected what seemed like reasonable servings of each by volume instead of weight (who knows what 100g of grapes looks like compared to 100g of watermelon?). I also provided the weight for reference, as well as the fiber content. The Keto Reset Diet does not recommend counting net carbs for fruit though.
Before getting to the data, note that this list omits foods like tomatoes and olives because that’s not what people mean when they ask about fruit.
Let’s also get two items out of the way that always appear on “keto approved fruits” lists:
Avocados: Is there any question about them being keto-friendly? So you know, one whole avocado (136 grams) has 12 grams of carbs (9 grams fiber), as well as 21 grams of fat.
Lemons: Most people aren’t eating lemons but juicing them, right? The juice from one whole lemon has 3 to 4 grams of carb (about 1 gram per tablespoon).
Now for the rest…
- Strawberries (½ cup halves, 76 grams): 6 grams carb (2 grams fiber)
- Blackberries (½ cup, 72 grams): 7 grams carb (4 grams fiber)
- Raspberries (½ cup, 62 grams): 7 grams carb (4 grams fiber)
- Blueberries (½ cup, 74 grams): 11 grams carb (2 grams fiber)
- Apricot (each, 35 grams): 4 grams carb (1 gram fiber)
- Plum (1 medium, 66 grams): 8 grams carb (1 gram fiber)
- Peach (1 medium, 150 grams): 14 grams carb (2 grams fiber)
- Nectarine (1 medium, 142 grams): 15 grams carb (2 grams fiber)
- Watermelon (1 cup cubed, 152 grams): 12 grams carb (1 gram fiber)
- Cantaloupe (1 cup cubed, 160 grams): 13 grams carb (1 gram fiber)
- Honeydew (1 cup cubed, 191 grams): 17 grams carb (2 grams fiber)
- Papaya (1 cup cubed, 144 grams): 16 grams carb (3 grams fiber)
- Pineapple (1 cup cubed, 165 grams): 22 grams carb (2 grams fiber)
- Banana (1 small, 101 grams): 23 grams carb (3 grams fiber)
- Coconut meat (½ cup, 163 grams): 25 grams carb (15 grams fiber)
- Mango (1 cup sliced, 165 grams): 25 grams carb (3 grams fiber)
- Clementine (each, 74 grams): 9 grams carb (1 gram fiber)
- Fig (1 medium, 50 grams): 10 grams carb (2 grams fiber)
- Kiwi (1 each, 69 grams): 10 grams carb (2 grams fiber)
- Orange (1 small, 96 grams): 11 grams carb (2 grams fiber)
- Apple, green (1 small, 144 grams): 20 grams carb (4 grams fiber)
- Grapefruit (1 small, 200 grams): 21 grams carb (3 grams fiber)
- Pear (1 small, 148 grams): 23 grams carb (5 grams fiber)
- Apple, red (1 small, 158 grams): 24 grams carb (3 grams fiber)
- Cherries (1 cup, 154 grams): 25 grams carb (3 grams fiber)
- Grapes (1 cup, 151 grams): 27 grams carb (1 gram fiber)
You can see why it is difficult to work fruit into a ketogenic diet, and also why blackberries and raspberries are the most often recommended fruit for keto-ers. Nevertheless, it’s possible.
Just for comparison, the 7 grams of carbs you “spend” on ½ cup of blackberries could also be allocated to any of the following:
- 1 cup of cooked whole Brussels sprouts
- 1 cup cooked chopped broccoli
- 2 cups of raw chopped broccoli
- 1¾ cups raw shredded cabbage
- 8 medium baby carrots
- 4 cups of baby spinach
- 5 cups of raw kale
- 1 whole small cucumber
- 1 medium red bell pepper
Tips For Incorporating Fruit Into Your Keto Diet
- Select lower-carb fruits and limit portion sizes.
- Eat whole fruit, not fruit juices. Whole fruits induce a smaller glycemic and insulin response. Smoothies can quickly become carb bombs, and they are generally less satiating than their ingredients eaten separately because you don’t have to chew them. Include smoothies mindfully.
- Consider timing them strategically around the times when you are most insulin sensitive: in the morning and especially after exercise. (This is solid advice for any higher carb food or meal.) Likewise, you might save fruit intake for designated higher carb meals (“carb ups”) if this is part of your routine. However, if you struggle with insulin resistance, any kind of carb ups might not be appropriate for you at this time.
- Eat seasonally and locally. This recommendation isn’t unique to keto dieters, but eating seasonally and locally will automatically limit your consumption of fruits for much of the year unless you live someplace warm (in which case, hopefully you’re getting lots of outdoor time and sun exposure year round, too!)
But I Heard I Need to Avoid Fructose For Health?
Fructose is often demonized because it’s thought (incorrectly) that fructose uniquely contributes to de novo lipogenesis. As Mark has written previously, although fructose and glucose are metabolized differently in the body, it is probably splitting hairs to argue that one is more or less healthy than the other when they are considered in the context of one’s entire diet. And while reducing sugar intake has been shown to improve various health markers, this usually means cutting back on high fructose corn syrup and other added sugars, not eliminating a green apple and a serving of berries. If you’re eating a Primal-aligned ketogenic diet and are already limiting your total sugar intake, it’s probably not necessary to specifically avoid fructose that comes in the form of whole fruit.
That said, some of the GI disorders that are so common nowadays might be attributable at least in part to issues of fructose malabsorption. If you have been diagnosed with IBS or otherwise experience chronic GI symptoms, you might consider asking your doctor for a hydrogen breath test to detect fructose malabsorption. You can also try eliminating and then reintroducing fruit to see if it affects your symptoms.
Remember, Constant Ketosis Is Not Required
If you’re avoiding fruit because you’re afraid to get knocked out of ketosis, remember that once you’re keto-adapted it’s unnecessary to stay in ketosis 100% of the time unless you’re using a therapeutic keto diet to treat a serious medical condition. Also, if there’s a fruit you especially want to include in your keto diet, you can also test your individual physiological response to it using a blood ketone meter.
A final word: When considering whether to add more fruit to your keto diet, ask yourself whether you’re still at a point where you would be better off abstaining in order to avoid triggering cravings for sweet foods. This is an n=1 situation. If you feel like some fruit would add to your general enjoyment of your keto way of eating, or you’re looking for ways to incorporate more Primal-approved carbs, go for it. If you’re still struggling to break the sugar habit, perhaps hold off for now, knowing you can always choose to add fruit later.
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Thanks to Paleohacks for today’s awesome keto recipe roundup!
Following the keto diet is a snap with these easy, one-pot recipes!
Skip the complicated recipes and keep dirty dishes to a minimum with these nourishing and delicious keto meals that are anything but boring. Think egg roll in a bowl with ground pork and plenty of deliciously stir-fried veggies, or whip up a quick pesto chicken for a simple Italian-inspired dinner. You can even update the classics with ultra-creamy tuna zoodle casserole.
Whatever you choose, there will be no slaving over a pot. We promise.
#1 Peace, Love and Low Carb | Pork Egg Roll in a Bowl
In need of a simple, one-pot stir-fry? This recipe will do the trick. Rife with veggies like onions and cabbage, this stir-fry gets its sweet and savory flavor from ginger, coconut aminos and rice vinegar. Add some spice with diet-compliant Sriracha or garlic-chili sauce.
#2 Paleo Scaleo | Chicken Bacon Ranch Casserole
Chicken, bacon and ranch are a winning combination, especially when prepared in a super-simple cauliflower rice-based casserole. Just be sure to use a diet-compliant ranch dressing!
#3 The Healthy Foodie | Creamy Cauliflower and Ground Beef Skillet
Ready for some soul food? Enjoy this hearty, creamy skillet packed with riced cauliflower, ground beef and eggs. The savory skillet works for any meal of the day, and gets its creamy texture from a blend of Paleo mayonnaise, sunflower seed butter, ghee and plenty of seasonings.
#4 That’s Low Carb?! | Low Carb Bacon Asparagus Breakfast Casserole
This eggy breakfast casserole is chock full of veggies like asparagus, celery and mushrooms. Simply mix everything together, pour into a casserole dish, and bake!
#5 The Nourished Caveman | Creamy Shrimp and Bacon Skillet
This bevy of seafood is made ultra-rich thanks to the addition of bacon, mushrooms and coconut cream. Feel free to serve this skillet as is or on a bed of zucchini noodles for a “shrimp scampi”-type dinner.
#6 PaleoHacks | Keto Turkey and Egg Breakfast Skillet
A hearty and sustaining breakfast is the best kind of breakfast, and this five-ingredient, super simple turkey and egg breakfast skillet fits the bill.
#7 Julia’s Album | One-Pan Pesto Chicken and Veggies
Everyone needs a go-to chicken and veggie recipe that’s completely foolproof. This simple and quick meal coats tender morsels of chicken and bright vegetables like tomatoes and asparagus with zippy pesto. It all comes together in 20 minutes, give or take.
#8 Paleo Plan | Paleo Shepherd’s Pie
Irresistibly hearty and rich shepherd’s pie is usually made with mashed potatoes, but that’s definitely not keto-friendly. This recipe channels the same starchy deliciousness using mashed parsnips instead, dolloped over a well-seasoned layer of ground turkey and veggies. Yum!
#9 Cotter Crunch | Jalapeño Shrimp Veggie Bake
This spicy, creamy shrimp and veggie bake is a flavor explosion. Succulent shrimp joins tender veggies like tomato, squash, onion and jalapeño in a creamy sauce. The addition of a gluten-free, grain-free flour option keeps things crispy and crunchy after a trip to the oven.
#10 Grass Fed Girl | Low Carb Hamburger Casserole
Ground beef and cauliflower are the base of this keto-friendly hamburger casserole. Spices like cumin, paprika and oregano add depth, while coconut milk (or cream) lends a silky mouthfeel. Finish with sliced almonds for crunch.
#11 PureWow | One-Pan Roasted Chicken with Carrots
Cheap, colorful, healthy, filling and flavorful, this meal ticks all the right boxes. Oven-roasted chicken thighs rest atop a bed of roasted rainbow carrots and garlic and seasoned with fresh rosemary.
#12 Paleo Scaleo | Paleo Buffalo Chicken Casserole
Get all the flavor of a Buffalo wing with none of the guilt in this one-pot, keto-friendly buffalo chicken casserole. Cauliflower, celery and carrots combine with shredded chicken, hot sauce and homemade mayonnaise for an ultra-rich but still good for you meal.
#13 PaleoHacks | Grain-Free Taco Casserole
Give taco night a keto makeover with this grain-free casserole. Spaghetti squash gets topped with ground beef and fresh veggies like tomatoes, shredded lettuce, and guacamole for all the fresh Mexican flavors you crave!
#14 Keto Karma | Keto Slow Cooker Chili
Slow cooker meals are the ultimate in one-pot recipes. This super simple beef and sausage chili simmers with peppers, onions and tomatoes for a rich dinner that requires only 15 minutes of prep.
#15 Cotter Crunch | Tuna Green Chile Zoodle Casserole
Do you love a good, classic tuna noodle casserole? Give it a keto makeover by nixing the grain-filled noodles for fresh, vibrant zucchini noodles. Pair it with sustainably caught, low-mercury canned tuna and you’re in for a real treat!
Thanks again to Paleohacks today. Do you have easy keto favorites to share—or questions about Primal/keto cooking? Share them below, and have a great week.
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