The Ketogenic Diet-McDonald

The Ketogenic Diet:
A complete guide for
the Dieter and Practitioner
Lyle McDonald
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This book is not intended for the treatment or prevention of disease, nor as a substitute for
medical treatment, nor as an alternative to medical advice. It is a review of scientific evidence
presented for information purposes, to increase public knowledge of the ketogenic diet.
Recommendations outlined herein should not be adopted without a full review of the scientific
references given and consultation with a health care professional. Use of the guidelines herein is
at the sole choice and risk of the reader.
Copyright: © 1998 by Lyle McDonald. All rights reserved.
This book or any part thereof, may not be reproduced or recorded in any form without permission
in writing from the publisher, except for brief quotations embodied in critical articles or reviews.
For information contact: Lyle McDonald, 500 E. Anderson Ln. #121-A, Austin, Tx 78752
ISBN: 0-9671456-0-0
FIRST EDITION
SIXTH PRINTING
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Acknowledgements
Thanks to Dan Duchaine and Dr. Mauro DiPasquale, and before them Michael Zumpano,
who did the initial work on the ketogenic diet for athletes and got me interested in researching
them. Without their initial work, this book would never have been written.
Special thanks to the numerous individuals on the internet (especially the lowcarb-l list),
who asked me the hard questions and forced me to go look for answers. To those same
individuals, thank you for your patience as I have finished this book.
Extra special thanks go out to my editors, Elzi Volk and Clair Melton. Your input has been
invaluable, and prevented me from being redundant. Thanks also goes out to everybody who has
sent me corrections through the various printings. Even more thanks to Lisa Sporleder, who
provided me valuable input on page layout, and without whom this book would have looked far
worse.
Finally, a special acknowledgement goes to Robert Langford, who developed the 10 day
ketogenic diet cycle which appears on pages 150-151.
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Introduction
I became interested in the ketogenic diet two and one-half years ago when I used a modified
form (called a cyclical ketogenic diet) to reach a level of leanness that was previously impossible
using other diets. Since that time, I have spent innumerable hours researching the details of the
diet, attempting to answer the many questions which surround it. This book represents the
results of that quest.
The ketogenic diet is surrounded by controversy. Proponents of the ketogenic diet proclaim
it as a magical diet while opponents denounce the diet because of misconceptions about the
physiology involved. As with so many issues of controversy, the reality is somewhere in the
middle. Like most dietary approaches, the ketogenic diet has benefits and drawbacks, all of
which are discussed in this book.
The goal of this book is not to convince nor dissuade individuals to use a ketogenic diet.
Rather, the goal of this book is to present the facts behind the ketogenic diet based on the
available scientific research. While the use of anecdotal evidence is minimized, it is included
where it adds to the information presented.
Guidelines for implementing the ketogenic diet are presented for those individuals who
decide to use it. Although a diet free of carbohydrates is appropriate for individuals who are not
exercising or only performing low-intensity aerobic exercise, it is not appropriate for those
individuals involved in high-intensity exercise. In addition to the standard ketogenic diet, two
modified ketogenic diets are discussed which integrate carbohydrates while maintaining ketosis.
The first of these is the targeted ketogenic diet, which includes the consumption of
carbohydrates around exercise. The second, the cyclical ketogenic diet, alternates a span of
ketogenic dieting with periods of high-carbohydrate consumption. In addition to an examination
of the ketogenic diet, exercise is addressed, especially as it pertains to ketogenic diets and fat loss.
This book is divided into seven parts. Part I includes an introduction to the ketogenic diet
and a history of its development. Part II presents the physiology of fuel utilization in the body,
ketone bodies, the adaptations to ketosis, changes in body composition, and other metabolic
effects which occur as a result of ketosis. Part III discusses the specific diets presented in this
book. This includes a general discussion of dieting principles, including body composition and
metabolic rate, as well as details of how to develop a standard, targeted, and cyclical ketogenic
diet. Part IV completes discussion of the ketogenic diet with chapters on breaking fat loss
plateaus, ending the diet, tools used to enhance the diet, and concerns for individuals considering
using ketogenic diet.
Part V discusses exercise physiology, including aerobic exercise, interval training, and
weight training. Additionally, the effects of exercise on ketosis and fat loss are discussed. Part VI
develops general exercise guidelines based on the information presented in the preceding
chapters. Part VII presents sample exercise programs, as well as guidelines for pre-contest
bodybuilders. Finally, Part VIII discusses the use of supplements on the ketogenic diet, both for
general health as well as specific goals.
This book is meant as a technical reference manual for the ketogenic diet. It includes
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information that should be useful to the general dieting public, as well as to athletes and
bodybuilders. Hopefully, the attention to technical accuracy will make it useful to researchers
and medical professionals. As such, technical information is necessarily presented although
attempts have been made to minimize highly technical details. Over 600 scientific references
were examined in the writing of this book, and each chapter includes a full bibliography so that
interested readers may obtain more detail when desired. Readers who desire further in-depth
information are encouraged to examine the cited references to educate themselves.
Lyle McDonald
Bio: Lyle McDonald received his B.S. from the University of California at Los Angeles in
physiological sciences. He has written for several publications, including two web magazines
(Cyberpump and Mesomorphosis), two print magazines (Hardgainer and Peak Training Journal),
and two newsletters (Dave’s PowerStore Newsletter and Dirty Dieting).
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Foreword
REGULATION OF KETOGENESIS
(Sung to the tune of “Clementine”)
In starvation, diabetes, sugar levels under strain
You need fuel to keep going saving glucose for your brain
Ketone bodies, Ketone bodies, both acetoacetate
And its partner on reduction, 3-hydroxybutyrate.
Glucagon’s up, with low glucose, insulin is down in phase
Fatty acids mobilised by hormone-sensitive lipase
Ketone bodies, Ketone bodies, all start thus from white fat cell
Where through lack of glycerol-P, TG making’s down as well.
Fatty acyl, CoA level, makes kinase phosphorylate
Acetyl-CoA carboxy-lase to its inactive state
Ketone bodies, Ketone bodies, because glucagon they say
Also blocks carboxylation, lowers Malonyl-CoA.
Malonyl-CoAs a blocker of the key CPT-1
Blocking’s off so now the shuttle into mito’s is begun
Now we’ve ß oxidation, now we’ve acetyl-CoA
But what’s to stop it’s oxidation via good old TCA?
In starvation, glucose making, stimulating PEP CK
Uses oxaloacetic, also lost another way
Ketone bodies, what is odd is that the oxidation state
Also favours the reduction of OA to make malate.
OA’s low now, citrate synthase, thus loses activity
So the flux into the cycle cuts off (temporarily)
Ketone bodies, Ketone bodies situation thus is this
Acetyl-CoA’s now pouring into Ketogenesis.
It’s a tricky little pathway, it’s got HMG-CoA
In effect it’s condensation in a head-to-tailish way
Ketone bodies, Ketone bodies, note the ratio of the pair
Is controlled by NAD to NADH everywhere.
Don’t despise them, they’re good fuels for your muscles, brain and heart
When you’re bodies overloaded though, that’s when your troubles start
Ketone bodies, ketone bodies, make acetone, lose CO2
You can breath those out, but watch out - acidosis does for you!
© “The Biochemists’ Songbook, 2nd ed.” Harold Baum. London: Taylor and Francis Publishers,
1995. Used with permission.
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Table of contents
Part I: Introduction 19. Interval training 200
1. Introduction to the ketogenic diet 11 20. Weight training 206
2. History of the ketogenic diet 13 21. The effect of exercise
Part II: The physiology of ketosis on ketosis 225
3. Fuel utilization 18 22. Exercise and fat loss 229
4. Basic ketone body physiology 28 Part VI: Exercise guidelines
5. Adaptations to ketosis 38 23. General exercise guidelines 239
6. Changes in body composition 52 24. Aerobic exercise 241
7. Other effects of the ketogenic diet 71 25. Interval training 245
Part III: The diets 26. Weight training 248
8. General dieting principles 86 Part VII: Exercise programs
9. The standard ketogenic diet (SKD) 101 27. Beginner/intermediate 260
10. Carbs and the ketogenic diet 120 28. The advanced CKD workout 266
11. The targeted ketogenic diet (TKD) 124 29. Other applications 270
12. The cyclical ketogenic diet (CKD) 128 30. Fat loss for pre-competition
Part IV: Other topics bodybuilders 278
13. Breaking fat loss plateaus 148 Part VIII: Supplements
14. Ending a ketogenic diet 152 31. General supplements 289
15. Tools for the ketogenic diet 158 32. Fat loss 292
16. Final considerations 166 33. The carb-load 302
Part V: Exercise physiology 34. Strength/mass gains 307
17. Muscular physiology and Appendices 309
energy production 174 Glossary 312
18. Aerobic exercise 180 Index 314
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Part I
Introduction
Chapter 1: Introduction to the ketogenic diet
Chapter 2: The history of the ketogenic diet
Prior to discussing the details of the ketogenic diet, it is helpful to discuss some
introductory information. This includes a general overview of the ketogenic diet as well as the
history of its development, both for medical conditions as well as for fat loss.
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Chapter 1:
Introduction to the ketogenic diet
Many readers may not be familiar with the ketogenic diet. This chapter discusses some
general ideas about ketogenic diets, as well as defining terms that may be helpful.
In the most general terms, a ketogenic diet is any diet that causes ketone bodies to be
produced by the liver, shifting the body’s metabolism away from glucose and towards fat
utilization. More specifically, a ketogenic diet is one that restricts carbohydrates below a certain
level (generally 100 grams per day), inducing a series of adaptations to take place. Protein and
fat intake are variable, depending on the goal of the dieter. However, the ultimate determinant of
whether a diet is ketogenic or not is the presence (or absence) of carbohydrates.
Fuel metabolism and the ketogenic diet
Under ‘normal’ dietary conditions, the body runs on a mix of carbohydrates, protein and fat.
When carbohydrates are removed from the diet, the body’s small stores are quickly depleted.
Consequently, the body is forced to find an alternative fuel to provide energy. One of these fuels is
free fatty acids (FFA), which can be used by most tissues in the body. However, not all organs
can use FFA. For example, the brain and nervous system are unable to use FFA for fuel ;
however, they can use ketone bodies.
Ketone bodies are a by-product of the incomplete breakdown of FFA in the liver. They
serve as a non-carbohydrate, fat-derived fuel for tissues such as the brain. When ketone bodies
are produced at accelerated rates, they accumulate in the bloodstream, causing a metabolic
state called ketosis to develop. Simultaneously, there is a decrease in glucose utilization and
production. Along with this, there is a decrease in the breakdown of protein to be used for energy,
referred to as ‘protein sparing’. Many individuals are drawn to ketogenic diets in an attempt to
lose bodyfat while sparing the loss of lean body mass.
Hormones and the ketogenic diet
Ketogenic diets cause the adaptations described above primarily by affecting the levels of
two hormones: insulin and glucagon. Insulin is a storage hormone, responsible for moving
nutrients out of the bloodstream and into target tissues. For example, insulin causes glucose to
be stored in muscle as glycogen, and FFA to be stored in adipose tissue as triglycerides. Glucagon
is a fuel-mobilizing hormone, stimulating the body to break down stored glycogen, especially in the
liver, to provide glucose for the body.
When carbohydrates are removed from the diet, insulin levels decrease and glucagon levels
increase. This causes an increase in FFA release from fat cells, and increased FFA burning in the
liver. The accelerated FFA burning in the liver is what ultimately leads to the production of
ketone bodies and the metabolic state of ketosis. In addition to insulin and glucagon, a number of
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other hormones are also affected, all of which help to shift fuel use away from carbohydrates and
towards fat.
Exercise and the ketogenic diet
As with any fat-loss diet, exercise will improve the success of the ketogenic diet. However,
a diet devoid of carbohydrates is unable to sustain high-intensity exercise performance although
low-intensity exercise may be performed. For this reason, individuals who wish to use a ketogenic
diet and perform high-intensity exercise must integrate carbohydrates without disrupting the
effects of ketosis.
Two modified ketogenic diets are described in this book which approach this issue from
different directions. The targeted ketogenic diet (TKD) allows carbohydrates to be consumed
immediately around exercise, to sustain performance without affecting ketosis. The cyclical
ketogenic diet (CKD) alternates periods of ketogenic dieting with periods of high-carbohydrate
consumption. The period of high-carbohydrate eating refills muscle glycogen to sustain exercise
performance.
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Chapter 2:
History of the Ketogenic Diet
Before discussing the theory and metabolic effects of the ketogenic diet, it is useful to
briefly review the history of the ketogenic diet and how it has evolved. There are two primary
paths (and numerous sub-paths) that the ketogenic diet has followed since its inception:
treatment of epilepsy and the treatment of obesity.
Fasting
Without discussing the technical details here, it should be understood that fasting (the
complete abstinence of food) and ketogenic diets are metabolically very similar. The similarities
between the two metabolic states (sometimes referred to as ‘starvation ketosis’ and ‘dietary
ketosis’ respectively) have in part led to the development of the ketogenic diet over the years.
The ketogenic diet attempts to mimic the metabolic effects of fasting while food is being
consumed.
Epilepsy (compiled from references 1-5)
The ketogenic diet has been used to treat a variety of clinical conditions, the most well
known of which is childhood epilepsy. Writings as early as the middle ages discuss the use of
fasting as a treatment for seizures. The early 1900’s saw the use of total fasting as a treatment
for seizures in children. However, fasting cannot be sustained indefinitely and only controls
seizures as long as the fast is continued.
Due to the problems with extended fasting, early nutrition researchers looked for a way to
mimic starvation ketosis, while allowing food consumption. Research determined that a diet high
in fat, low in carbohydrate and providing the minimal protein needed to sustain growth could
maintain starvation ketosis for long periods of time. This led to development of the original
ketogenic diet for epilepsy in 1921 by Dr. Wilder. Dr. Wilder’s ketogenic diet controlled pediatric
epilepsy in many cases where drugs and other treatments had failed. The ketogenic diet as
developed by Dr. Wilder is essentially identical to the diet being used in 1998 to treat childhood
epilepsy.
The ketogenic diet fell into obscurity during the 30’s, 40’s and 50’s as new epilepsy drugs
were discovered. The difficulty in administering the diet, especially in the face of easily prescribed
drugs, caused it to all but disappear during this time. A few modified ketogenic diets, such as the
Medium Chain Triglyceride (MCT) diet, which provided greater food variability were tried but they
too fell into obscurity.
In 1994, the ketogenic diet as a treatment for epilepsy was essentially ‘rediscovered’ in the
story of Charlie, a 2-year-old with seizures that could not be controlled with medications or other
treatment, including brain surgery. Charlie’s father found reference to the ketogenic diet in the
literature and decided to seek more information, ending up at Johns Hopkins medical center.
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Charlie’s seizures were completely controlled as long as he was on the diet. The amazing
success of the ketogenic diet where other treatments had failed led Charlie’s father to create the
Charlie Foundation, which has produced several videos, published the book “The Epilepsy Diet
Treatment: An introduction to the ketogenic diet”, and has sponsored conferences to train
physicians and dietitians to implement the diet. Although the exact mechanisms of how the
ketogenic diet works to control epilepsy are still unknown , the diet continues to gain acceptance
as an alternative to drug therapy.
Other clinical conditions
Epilepsy is arguably the medical condition that has been treated the most with ketogenic
diets (1-3). However, preliminary evidence suggests that the ketogenic diet may have other
clinical uses including respiratory failure (6), certain types of pediatric cancer (7-10), and possibly
head trauma (11) . Interested readers can examine the studies cited, as this book focuses
primarily on the use of the ketogenic diet for fat loss.
Obesity
Ketogenic diets have been used for weight loss for at least a century, making occasional
appearances into the dieting mainstream. Complete starvation was studied frequently including
the seminal research of Hill, who fasted a subject for 60 days to examine the effects, which was
summarized by Cahill (12). The effects of starvation made it initially attractive to treat morbid
obesity as rapid weight/fat loss would occur. Other characteristics attributed to ketosis, such as
appetite suppression and a sense of well being, made fasting even more attractive for weight loss.
Extremely obese subjects have been fasted for periods up to one year given nothing more than
water, vitamins and minerals.
The major problem with complete starvation is a large loss of body protein, primarily from
muscle tissue. Although protein losses decrease rapidly as starvation continues, up to one half of
the total weight lost during a complete fast is muscle and water, a ratio which is unacceptable.
In the early 70’s, an alternative approach to starvation was developed, termed the Protein
Sparing Modified Fast (PSMF). The PSMF provided high quality protein at levels that would
prevent most of the muscle loss without disrupting the purported ‘beneficial’ effects of starvation
ketosis which included appetite suppression and an almost total reliance on bodyfat and ketones
to fuel the body. It is still used to treat severe obesity but must be medically supervised (13).
At this time, other researchers were suggesting ‘low-carbohydrate’ diets as a treatment for
obesity based on the simple fact that individuals tended to eat less calories (and hence lose
weight/fat) when carbohydrates were restricted to 50 grams per day or less (14,15). There was
much debate as to whether ketogenic diets caused weight loss through some peculiarity of
metabolism, as suggested by early studies, or simply because people ate less.
The largest increase in public awareness of the ketogenic diet as a fat loss diet was due to
“Dr. Atkins Diet Revolution” in the early 1970’s (16). With millions of copies sold, it generated
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extreme interest, both good and bad, in the ketogeni...