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Chapter 11: From Low Carb to Keto

Looking back now, when I first tried the keto diet, I was not well-prepared. As you may have realized by now, I am impatient, a bit of a workaholic, with a dash of obsessive-compulsiveness. I want everything done yesterday! But, especially when it comes to the delicate balance of the human body, rushing can backfire. For example, transitioning from the low-carb to the keto diet isn’t as simple as it appears.

My aim had been to try out the diet and share the results with my fellow diabetics, so I began my journey with only a shallow understanding. As you heard in the previous chapter, my new diet lacked potassium and magnesium, leading to problems with my health and heart rate. In the end, I was still in a rush to find out all I could - it seems this is just my nature.

I remember when I started at Tsinghua University and suddenly noticed how intelligent all my classmates were. Back in middle school, I could play while studying and still stroll through my classes with high grades. The director of the farm even came to my home to try to persuade my parents to get me into the local high school, in order to scale up their grades! Among my classmates at Tsinghua, that proud feeling quickly evaporated. I was so anxious that I could not sleep at night and even developed canker sores, but it was all over nothing. After chatting with my classmates, I realized that everyone was as anxious as me.

Making the transition from being a big fish in a small pond to a small fish in a bigger pond is never easy. But that does not mean that you should stop striving. My transition from the low-carb diet to a keto one was challenging. But I had a worthwhile aim - I was fighting for the wellbeing of my fellow diabetics. I couldn’t give up.

Why was I determined to try keto? On a low-carb diet, diabetics will inevitably consume a tiny amount of starch, which is then converted to glucose. This glucose sits, like a beast lying in wait, ready to strike at any time.

On the keto diet, the intake of carbohydrates is near-zero, which means the beast is no longer a threat. Furthermore, if the low-carb diet passively fights against diabetes by reducing the intake of carbohydrates, then the keto diet would theoretically be even more effective in treating it. On the keto diet, the supply of basic nutrients is guaranteed, and the calorie-in-calorie-out equation is balanced, with the intake being less than the consumption, which can increase the sensitivity of insulin and improve the insulin-glucose ratio. Improving insulin sensitivity has an active treatment effect on diabetes.

For the sake of resolving future problems together with my fellow diabetics, I had to see the journey to its end. Simply put, the keto diet has a comparably higher fat intake and a strict limit on carbohydrate intake. When a human body has little or no carbs at its disposal , the liver will convert an appropriate amount of fat into ketones and release them into the bloodstream. The ketone concentration in the bloodstream is maintained at 0.5-3 mmol/L, and although the blood glucose concentration drops, the pH value of the blood does not change. The human body can function in a healthy condition while combating diabetes.

Although the keto diet can be seen as an upgraded low-carb diet, it actually came into existence earlier than the high-fat, low-carb diet. It first appeared as a treatment for childhood epilepsy. The accepted treatment at the time was controlled starvation but this negatively affected the patients’ long-term metabolism, as well as being obviously unpleasant.

In 1921, Dr. Wilder of the Mayo Clinic in the U.S. first proposed a type of keto diet that simulated the metabolism effects of famished conditions. A study of 17 epilepsy patients was undertaken, and in a 1924 report by American Dr. Peterman, 10 of them managed to get their condition completely under control. Of those 10, 9 used only the keto diet without any other supplementary treatment methods.

After the development and production of special medications for epilepsy, the keto diet was left by the wayside for some time. In the 1960s, it was a popular choice for athletes who were part of intensive sports, since they needed to maintain a large energy intake while controlling their weight.

Later on, more and more knowledgeable people started using the keto diet as a practical way to combat diabetes.

●The ski-lover Dr. Jay Wortman has been following the keto diet plan faithfully for 16 years and providing a keto prescription for his diabetic patients.

●The American scholar Sami Inkinen, who rowed 4,000 km from California to Hawaii, highly recommends the keto treatment via his company Virta Health.

●Steve Phinney has been living a keto life for over 40 years. He is over 70 years old but is still healthy and active.

However, the debate over the keto diet is far more heated than over the low-carb diet. We have already seen how pressure from for-profit corporations has reduced support for the low-carb diet. When it comes to Keto, things go up a notch. Messages about the supposed dangers of the diet can be found everywhere.

For example, some say that the keto diet causes a rise in blood fat content and a lack of micronutrients and minerals, and that it leads to a higher risk of kidney stones. Moreover, when the body is taking in less carbohydrates, it will start to break down fat, which can easily produce acidic metabolites and even lead to metabolic acidosis, also known as ketoacidosis.

This all sounds terrifying, but we have seen the tricks that for-profit corporations used with smoking and still use with diabetes treatments. So, can we make an educated guess that the harder they deny a treatment, the more effective for reversing diabetes it actually is?

Even for the regular low-carb diet, I had to spend several years finding out the reason why my doctor did not provide it as a treatment option before I felt confident to share it with my fellow diabetics. As for the keto diet, which has sparked off even wider debates in the medical field, I needed more time to learn about and apply it before sharing my conclusions.

That time has arrived.

A fellow diabetic asked me on WeChat, “How do I check for ketoacidosis?” This is a very common question. Generally speaking, the main reason for concerns over the keto diet is ketoacidosis. This is a serious topic, so I must explain it through professional medical terms.

Ketone bodies are a metabolite that is created when the liver breaks fat down into fatty acids. They include acetoacetic acid, β-hydroxybutyrate, and acetone. Under normal circumstances, the body produces a small number of ketone bodies, which are then delivered to the heart, lungs, kidneys, and skeletal muscles via the bloodstream to be metabolized into energy. The ketone body concentration in the bloodstream is very low, usually under 1.0 mg/dL, and it usually cannot be detected in urine.

When the body does not have enough insulin or sugar, such as in starvation, fasting, severe gestation reaction situations, fat will be over-metabolized, and the concentration of ketone bodies will be too high. Some of the ketone bodies can be expelled from the body through urine. When the liver produces more ketone bodies than can be used by other tissues and organs, the blood-ketone-body concentration will be too high, causing ketonemia and ketonuria. The acetoacetic acid and β-hydroxybutyrate found in ketone bodies are acids and can lead to acidosis, also known as ketoacidosis, when too much of those are built up in the bloodstream.

In other words, ketoacidosis only occurs when the liver produces more ketone bodies than can be used by non-liver tissues. It is not yet known whether there is a causative connection.

In reality, over-consumption of alcohol or insulin can cause hypoglycemia, which signals the liver to start breaking down fat and even muscles in the body, leading to ketoacidosis. Does that mean we should never drink and never take insulin? No sensible for-profit organization would promote abstinence from alcohol and insulin consumption.

By the way, many believe that diabetics should quit drinking alcohol completely, but that is not necessarily true. There can be some benefits for diabetics to drink an appropriate amount of alcohol. Our blood glucose level drops after drinking alcohol due to our liver metabolizing the ethanol and producing less glucose.

You cannot take anything you read at face value. Rather you must carefully filter the information around you.

The structure of the keto diet is as follows:

A. Net carbohydrates: less than 50 g/d.

B. Proteins: 1 g/ (kg ·d).

C. Fat intake should depend on the base metabolic rate. Consume foods that are rich in omega-3 fatty acids such as salmon, tuna, saury, and sardines. Also consume foods that are high in mono-unsaturated fats and fatty acids such as avocado and olive oil.

D. Dietary fibers: 30 g/d, split into two meals of 15 g each.

E. Water: at least 2,000 mL/d.

F. Sufficient dDaily vitamin and micronutrient supplements.

The dietary structure above is a typical outline, as the specifics will vary from person to person. In light of the strictness of the keto diet and everyone’s body being different, these three points should be carefully considered.


Just as the labels on medications tell you to always follow the physician’s directions, the keto diet is best followed under the guidance of a professional institution. I consider the keto diet to be very similar to Chinese herbal medicine. Historically, Chinese people have all considered themselves to be a traditional Chinese medicine practitioner to some degree.

They will brew some honeysuckle or chrysanthemum tea when they are feeling dryness-heat or stew some liquorice or siraitia when they have a sore throat. But that does not mean everyone can just be their own doctor. The herbs will cause problems if used in excess.


It is best to gradually reduce your carbohydrate intake. The keto diet is usually split into 3 steps:

The beginning stage (2-12 weeks):

This jump-starts our bodies’ own fat metabolism functions through a reasonable keto diet and a suitable amount of exercise combined with comprehensive guidance and follow-up service from a professional nutritionist.

The transitional stage:

After basically reaching the goal of reducing our blood glucose level, we gradually transition from the beginning stage diet to a regular low-carb diet.

The sustaining stage:

A long-term dietary plan set out by a professional nutritionist based on the specific physical conditions of each diabetic; it is a mutually complementary hybrid diet between the keto diet and the regular low-carb diet.

If any difficulty, changes in liver or kidney functions, or hyperuricemia arises at any of the above stages, the keto diet must be stopped, and you can switch to the transitional stage diet to monitor for any more changes.


Changing from a keto diet back to a regular low-carb diet should also be done gradually. The zero-carb keto diet can be followed in the long term, or for a short time just as a treatment. For many diabetics who are not in a serious condition, they can gradually return to a regular, standard low-carb diet after recovering from their illness. However, during that process, they should not immediately start consuming a normal quantity of carbohydrates, since their islet function is still not quite robust at this point, and overloading them will cause an adverse reaction.

A small quantity of carbohydrates should be consumed at first – 20 g per meal, for example, then increased to 25 g after a few weeks, and so on. The islet functions should be trained and strengthened gradually, ideally over one or two years, before a complete switch to a regular low-carb diet.

You absolutely cannot be too hasty and increase the amount too quickly. Never ever allow your blood glucose level to reach over 7.8 after a meal. This is a hard rule. There can be hidden adverse effects in the keto diet as well, although they are mostly temporary and will naturally disappear once the body adjusts to using ketone bodies instead of sugar as the main energy source.

1. Hypoglycemia effects:

4 to 7 days after restricting carbohydrates, and partial fat reduction, you may experience hypoglycemia symptoms such as weakness, nervousness, palpitations, and cold sweat. Normally, these will disappear one week into the keto treatment. Check your blood glucose level whenever necessary. If it is >3.9 mmol/L and there are no symptoms, you do not need to take any action. If you experience any typical signs of hypoglycemia (such as drowsiness, sweating, weakness, or looking pale), and your blood glucose level is <3.9 mmol/L, you can take actions accordingly.

You should also adjust your keto diet. Follow a flexible keto diet by gradually reducing the carbohydrate ratio in your meals and reaching the low-carb goal of the keto diet eventually, and you will significantly reduce the negative effects mentioned above.

2. Feelings of hunger:

During the process when the body is adjusting to using ketone bodies as the main energy source, feelings of hunger are normal. As time goes by, and your body gradually adjusts to the keto lifestyle, the feelings of hunger will gradually disappear. This process can take a few weeks.

3. Flushed cheeks and increased heart rate:

In the first week of keto, a small number of diabetics will have flushed cheeks and an increased heart rate. They may be caused by hypoglycemia, the production of ketone bodies, or a mild case of acidosis. Check your blood glucose level regularly and if hypoglycemia occurs, treat it the same as above.

4. Irritated skin and rubella:

The respiratory tract, the skin, and the urinary tract are the three main channels through which the body expels ketone bodies. A small number of diabetics may have an allergic reaction on their skin to excreted ketone bodies, causing itchiness and rubella. This can be mitigated by showering twice per day using a weak base bath lotion for 1 to 2 weeks. At the same time, reduce the proportion of fat intake when necessary for less ketone bodies production.

5. Constipation:

The keto treatment is a low-fiber and low-residue diet; therefore, constipation is a common clinical symptom. It can also be related to a lack of minerals, such as magnesium, or dehydration. It can be addressed by using medications that increase bowel movements, such as taking mosapride citrate, magnesium supplements, or dietary fiber.

Although my concern is mainly for diabetics, I believe that the low-carb diet is beneficial for anyone. When it comes to the keto diet, however, I am convinced that it is an effective treatment for diabetes, but it should be used under the guidance of a professional institution.

Ethan Weiss, a professor of research in cardiology at UCSF once said that we cannot reject this great diet simply because it is imperfect. In other words, the current mainstream diets are much worse in comparison.

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