The Pitfalls of the Ketogenic Diet and Intermittent Fasting

It’s almost over… and so soon.

#NewYearNewMe is almost done trending. We’re at the end of January, and most people will give up on their resolutions in 3…2…1….

I’m not being a Negative Neally. I hope you don’t give up. I want habits to change, goals to be met, and most importantly, lives to be lived healthier.

It’s tough to do. Particularly so, because everyone has a gimmick. Everyone’s promoting some trick to make it easier. #NewYearNewFad.  

This year is no different, as there are two major diets infecting every corner of the media: The Ketogenic Diet and Intermittent Fasting.  

If you’re “on the social media” as the kids say, you’ll see what seems like 100% success stories posted everywhere. Are their gainz (or losses) urban legend, or are they real?

I’ve been sitting on this for a bit, just waiting for January to roll around to unleash my rantiness!!

Today, we discuss these two diets, the pros, the cons, and give a little Neal Narrative on the whole scene.

I hope to answer all your Keto and Intermittent Fasting questions, but especially the big question: Why do we as a society act like we’ve never seen fad diets like these before?

The Ketogenic Diet (KD or Keto) and Intermittent Fasting (IF) have caught on like wildfire. They’re making big waves. They’re raising the roof and bringing down the house. If I weren’t aware of the power of trends on social media and their virality, I’d probably believe that the two newest diet fads were actually something good, not more of the same old stuff.

I’ve said many diets are dumb. As evident by the first few paragraphs here, I’ve gotten to the point where I can’t even try to be professional when talking about them. Let’s look at each diet and evaluate the good, the bad, and the ugly.

Ketogenic Diet

The Ketogenic Diet, also called KD or Keto, is a diet that turns the normal macronutrient recommendations on their head. Instead of the modern, evidence-based recommendations of 50% good carbs (fruits, veggies, whole grains) and the remaining 50% protein and good fat (heavier on the protein), a Keto diet says to get 50-70% fat, 25-35% protein, and 5-10% carbs. By dramatically reducing the amount of carbs, we induce what is called a ketogenic state. Crossing the border into ketogenesis is the goal for the diet. What does that mean? Let’s look at that in more detail!

The Ketogenic State of Mind

This stuff gets geeky and complicated, but I think I can simplify it all. The best analogy, I think, is to consider your body a hybrid vehicle. It runs primarily off electricity, but it can use gas. Heck, sometimes it even needs the gas. But it would be really weird if you used only gas and tried to minimize your electricity. I mean, why buy a hybrid?

Carbohydrates are the major fuel source for humans – the electricity in this example. We can use fats and proteins as a fuel source if times get tough, but mostly they’re there just in case – just like the gas.

When you reduce your carbs so dramatically as you do in the Keto diet, your body switches gears. First, the amount of electricity available goes down to far below what our car needs to keep moving. Don’t fret, we have a reserve; we then use up whatever fuel is in the battery. We store about a day’s worth of calories in the body as glycogen – carbs bound to water molecules. In the absence of new dietary carbs, our body will first use up the glycogen stores.

By using up our glycogen stores, we will notice a rapid weight loss of about 2-8 pounds, as the water molecules found in the glycogen are released. This is the “water weight” people talk about around diets.

Once they glycogen is depleted, we then switch on the reserve systems. Our liver tries making sugar, and it does, but there’s no way the liver can produce enough consistently to be a fuel source. Your body is forced to the ketogenic state, where it melts down fats to create ketone bodies. Ketone bodies are your new best friend and new fuel source.

Melting fat is cool. This is one of the benefits to Keto diets: besides the rapid water weight loss, fatty tissue will become our energy source, leaning people down without attacking muscle stores like traditional diets.

It should be noted that the MINUTE carbs are reintroduced to take you out of a ketogenic state, your body will turn off ketogenesis and even start rebuilding the glycogen stores – causing the water weight to get put back on!

As long as carb intake is kept very low, your body will stay in a ketogenic state. Ketones could change blood pH, which results in a VERY dangerous situation. Nutritional ketosis, however, is considered safe since the ketone bodies are produced in such small amounts.

What You Can Eat

The Ketogenic Diet has 2 major dietary modifications: eat lots of fat and eat very little carbohydrates. So do we just chew on the edges of a steak and drink french fry oil? Can we eat ANY fruits or vegetables, or are they all off the table? Let’s clarify the whole thing.

We want to make the healthiest fat choices, not just indiscriminately eat unhealthy fats. You can do so by eating things like fatty fish, avocados, and nuts. Someone on the Keto diet will probably ingest more saturated fat than is recommended by most professional organizations. Bacon and red meat are encouraged, so that’s pretty awesome, yet it leaves me scratching my head.

MCT, or medium chain triglycerides, are often recommended for the Keto diet. Things like Omega-3’s are long chain triglycerides. Coconut oil is a popular MCT. They are really great for Keto dieters because of how readily available MCTs are as a fuel source, and ingesting MCT helps with any of the weird feelings you get changing your diet at the beginning.

MCT and coconut oil isn’t that healthy for you. Getting excess coconut oil, butter, or the like will increase the risk of heart disease. The picture is less clear with Keto as MCT is a fuel source and may not be consumed in excess. Still, I get freaked out hearing about how much people eat of this stuff while on Keto.

From a carb standpoint, they want to eliminate white/processed carbs, whole grains, and starchy vegetables. No corn, sugars, pasta, beans, or rice. This means you can eat things like berries, plums, cantaloupe, coconut, or avocado. Olives are recommended for their fat and antioxidant properties.  

There are a million of these out there, but here’s an image of the “Food Pyramid” for Keto:

The Keto Diet Works

Pushing your body to ketosis is a pretty effective way to lose weight. You have a rapid weight loss due to the water loss, which is a big plus for people psychologically. It’s encouraging!

Like all diets, your hunger pangs subsides and further reduction in calories normally follows, speeding up weight loss.

What’s most beneficial, though, is the impact on insulin. Insulin is secreted to regulate blood glucose levels. People who have too much glucose from a carb-heavy diet will be secreting LOTS of insulin for a long time. Your body gets numb to it, causing insulin resistance and starting you off down a road to diabetes. When you almost completely eliminate carbs like in the Keto diet, you improve metabolic syndrome, insulin resistance, and blood sugar levels. Your insulin levels fall off. The pancreas doesn’t have to work as hard as before. Your body’s cells become sensitive to the effects of insulin again. You can quickly and efficiently reduce Type 2 Diabetes, and in some cases eliminate it.

Most health professionals will look at this diet and say, “Dude man yo their cholesterol is going to go through the roof.” That’s how we talk when you’re not around. The dramatic intake of fats, in many cases “bad fats”, would typically lead to elevated LDL numbers and those LDL molecules would be small and dense, which means they’re more likely to cause major cardiovascular problems in the future. That’s what practice has taught us to expect.

In the data we have, it seems this is NOT the case. Cholesterol profiles improve! Lower LDL, higher HDL, triglycerides fall to insanely low levels, and LDL molecules are light and fluffy. They wouldn’t hurt a fly, let alone your achy-breaky heart.  

Keto Sounds Great!

“Why in the world are you ranting Neal? This diet sounds awesome!” Great question, I aim to deliver. As you can bet, it’s not all sunshine and rainbows.

The data we have on the Keto diet is short term and of varying quality. When we look at Keto on a longer timeline or with larger populations and better study controls, those benefits fade. There’s even some data that ties Keto to poor blood glucose control in the early phases. If we are going to use a few blips – small numbers of small studies – to promote Keto, we should be willing to use other blips – small numbers of longer term studies – to poo-poo it.

I’m willing to put $5 down to say that over time, the cholesterol profile for someone on the ketogenic diet will shift towards unhealthy, especially with Keto diets rich in saturated fats.  

Cholesterol is only a marker of cardiovascular disease, so watching those numbers change are a small part of a big picture. The big question: Will Keto diets reduce the risk of strokes, heart attacks, or heart disease?

Keto is difficult to implement and get right initially. It’s insanely difficult to do on a long term basis.  

Keto does not concur with the USDA, the FDA, AHA, or ADA with their recommendations of low saturated fat and whole grains, fruit, and vegetable intake. There’s LOTS of data there, compared to some small highlights for keto.

We get vitamins and micronutrients mostly from our good carbs. Many people who do keto will have micronutrient deficiencies. Studies in pediatric populations (who have been using keto to reduce seizures in epilepsy for some time) show up to 28 different deficiencies including B Vitamins and minerals. As I’ve been saying for some time, a vitamin is NOT the same as the food, so while you can replace the vitamin, the nutrition from vitamin-rich foods cannot be so easily replaced.

Other complications include fatty liver, low protein levels in the blood, and kidney stones.

Neal’s Keto Recommendation

Keto isn’t bad, but I won’t full out support a Keto diet. That is, until we have better data. Before I recommend the Keto diet, I want to conclusively know that diet makes people healthier. I don’t care about weight loss or cholesterol. Will doing this diet make people less likely to die or suffer from heart disease, Alzheimer’s, or cancer?

My hunch is that compared to the American/Train Wreck Diet, yes, people will be healthier. That’s a no brainer – obesity, diabetes, and high blood pressure caused by overeating unhealthy foods will always lose to a well disciplined Keto diet. Is this diet any better than a disciplined Mediterranean diet or even a vegan diet? How do the safety profiles compare?  

This is essentially Atkins: The Sequel. Dramatic carbohydrate elimination is a no-brainer because most of us eat way too many simple carbs. Atkins long term data isn’t that good, so I don’t have much faith in Keto being better.

An analogy: We still hear about how non-celiac patients going gluten-free “changed their lives” and all that jazz. My rhetorical question has always been, “Did you need to go gluten-free or would it have been sufficient to go gluten-less?” We don’t have that data for gluten, but we do for Keto. A moderate reduction in simple carbs and modest consumption of healthy fats is PLENTY to be healthy, controlling heart disease risk factors rather quickly.

Keto, to me, is a bit dramatic, unsustainable, potentially dangerous, and lacking long term data to know if the short term benefits of weight loss, blood sugar control, and improved cholesterol will last.

Intermittent Fasting

Intermittent Fasting is a diet that says, “The best way to lose weight is to not eat… sometimes.” Fasting is a term used for abstaining from food or drink over a period, usually performed by people better than me. Intermittent Fasting, then, is the cycling between times of fasting and times of allowed eating. I used to call this sleeping vs being awake, but what do I know?

The theory on intermittent fasting is that it allows the benefits of fasting – weight reduction – without allowing the body to adapt to the fasting itself, where it would slow metabolism as a result of no calories coming in and slow further weight loss.

What You Can Eat

This diet is less about what you can eat and more about when. There is no restriction of the types of foods you can eat, though the recommendations will always be to eat healthier foods.

There are a few different types of Intermittent Fasting approaches.  Here are a few examples:

  • Alternate-day fasting — Alternating between days of no food restriction with days that consist of one meal that provides about 25% of daily calorie needs. Example: Mon-Wed-Fri consists of fasting, while alternate days have no food restrictions.
  • Whole-day fasting — 1-2 days per week of complete fasting or up to 25% of daily calorie needs, with no food restriction on the other days. Example: The 5:2 diet approach advocates no food restriction five days of the week, cycled with a 400-500 calorie diet the other two days of the week.
  • Time-restricted feeding — Following a meal plan each day with a designated time frame for fasting. Example: Meals are eaten throughout the day from 8am-3pm, with fasting during the remaining hours of the day.

Psychologically, I get this diet approach. Calorie reduction is hard to sustain over a long period of time. It may be easier to keep your will power going for an 8 hour stretch than it is to be hungry all the time for a couple weeks.  

The Positives of Intermittent Fasting

There are some good things about this diet, so don’t call me Captain Negative… First, unlike Keto, we’re not restricting any macronutrient group. Eat whatever, as long as it is healthy.  

Fasting – not intermittent fasting – has been shown to improve markers of disease like weight, blood sugar, oxidizing compounds, and more. The data around fasting, though, is mostly in animals. I take this with a grain of calorie-restricted salt, because animal results may be VERY different from human results. In animals, for example, the Keto diet worsens cholesterol.

We found one study that supports the idea that IF is more likely to conserve lean muscle mass and burn fat, while normal calorie restricted diets cause muscle AND fat loss (without exercise).

For positives, that’s about it. There are many negatives…

The Negatives of Intermittent Fasting

IF can’t be used in people that NEED food at regular intervals, like diabetic patients.

In the beginning, not eating has pretty dramatic negative effects such as hunger, weakness, fatigue, and brain fog. Just what everyone wants! Honestly, half my questions throughout the day are about how to address a lack of energy and brain fog. My advice is always EAT MORE FREQUENTLY!

Intermittent fasting, and fasting in general, is the complete opposite of what the best science tells us. In order to feed our body to be proper corporate slaves, we need regular, consistent, dense fuel sources. Being hungry is a painful signal for a VERY good reason!

When we get hungry and ignore the signs, our body starts to think we’re going to hibernate. Instead of ramping up to burn calories as we tend to believe (I am hungry, I’ll burn calories), our metabolic rate slows. We start to store fuel for use later. How we secrete insulin and glucagon changes – and long term this has been shown to increase insulin resistance.  

Exercise and fitness is a crucial part of wellness. It helps us move blood, get our hearts healthy, and improves muscle development. Most importantly, our metabolic rate rises. If we work out but have periods of hunger regularly, does our average metabolic rate rise, fall, or stay the same?  If we truly want to optimize our metabolic rate via exercise, we’d want to be sure we aren’t actively suppressing it via a poor diet. You need to eat to be your healthiest.

You NEED to eat regularly, but you will fail with exercise without having nutrients available to handle the extra energy for the work out.  “You won’t outrun your gut” was told to me years ago, and it helped me understand that we use exercise for fitness, not weight loss. With exercise, our caloric needs increase right before and directly after exercise, and fasting conflicts with that.

Don’t most people diet because they’ve gone off the healthy food wagon? They’ve binged from October to January, now they have to shave it down a bit.  *cough* me *cough* You still need control while fasting, and I’m willing to bet more people will not have the control needed during feeding times and could possibly binge.

One more major gripe: the worst part of a diet are the hunger pangs from calorie restriction. Those come as your body is getting used to going from a Thanksgiving dinner worth of addicting foods each meal down to a normal, healthy diet. Those pangs also come from the physical shrinking of your stomach. Your stomach has stretched out to accommodate the volume of food you eat, and it takes a couple weeks for the stomach to go back to normal size. With intermittent fasting, we’re constantly re-stretching the stomach as we binge eat over a short period, instead of slowly reducing the amounts we eat all day, allowing the stomach to slowly shrink down to a smaller size.

The different fasting schedules don’t improve adherence; people are as likely to quit no matter what cycle they choose.

Just like Keto, the IF diet doesn’t concur with the USDA, FDA, AHA, or ADA dietary recommendations, nor does it help you learn how to make better, healthy changes to your diet. At least none that are any different than traditional diet advice. It literally just focuses on calories, and as we’ve shown, you can eat oreos and lose weight.

Neal’s Intermittent Fasting Recommendation

Don’t do it.  That’s about it.  Intermittent Fasting helps some people lose weight, and less weight can make people healthier.  If you still eat junk, whether you take a break from it via a fast daily or weekly or whatever, you still are putting unhealthy foods into your body.  Compared to regular diets with calorie restriction, IF is no better at helping people lose weight. I’d argue that for many, especially with those who exercise, it will decrease energy, clarity, and mental performance.  It’s just another gimmick.

It Doesn’t Have To Be So Crazy – Our Dietary Recommendations

If you’ve been with me since my professional start, you’ll know my rap on this hasn’t changed much. I’ve just refined how I explain it. I can now do so with less curse words.

You can read my campfire blog and learn all about the Wellness Pyramid to get the indepth take on this, but here it is, nice and quick-like:

  • Eat within 30-60 minutes of waking
  • Eat small, frequent meals and snacks throughout the day
  • A meal and snack should have all macronutrients – proteins, good fats, and good carbs (fruits, veggies whole grains)
  • Limit, if not eliminate, simple carbs like bread, pasta, and rice
  • Half of each meal or snack should be good carbs, the other half should be mostly protein and some good fats
  • Strive to hit your macronutrient goals, especially protein, as that one is often missed (It’s approximately your weight in kg, or your American weight divided by 2.2)
  • Try to get the highest quality food you can – local, sustainably, ethically, and properly grown or raised, with as-little-as-possible chemical involvement (antibiotics, hormones, pesticides, herbicides)
  • Avoid processed, packaged foods, fake butter (margarine), foods rich in sweeteners and added sugars. That stuff’s addicting.
  • Vary your diet to get exposed to lots of micronutrients (vitamins and friends). Eat both raw AND cooked foods as they offer differing micronutrients based on preparation. Except meat – try not to eat that raw.

Eating in this manner will provide 3 amazing benefits:

  1. Consistent blood sugar.
  2. Reduced hunger, as you’ll be satiated more. You’ll have lasting fuel sources instead of high peaks or cliffs of energy you can fall off.
  3. More consistent energy levels, which in turn leads to less fuzzy, foggy thinking.

Fasting is just out. It does the opposite of what we want, metabolically. You can call this nutritional advice “Lazy Keto”, especially if you get a bit more aggressive with the simple carb restriction but don’t go into a state of ketosis, all while eating a healthy amount of protein and unsaturated fats. But in general, the fad diets put forth here today are Version 3 or 4.0 of the same old song and dance – unsustainable and potentially harmful, with little benefit over a long time scale.

And this isn’t just what Neal thinks. Check out the American Heart Association, the American Diabetes Association, and the Alzheimer’s Association. They’ll say some version of what I’m saying. I point to these 3 the most because heart disease, diabetes, and Alzheimer’s disease are the boogeymen. Our modern lions, tigers, and bears are these diseases. We don’t need Keto or IF to fend these baddies off.  It’s not like Keto or IF are some special karate or BJJ moves to put them in a headlock. We literally allow these predators into our house then taunt them with a poker. We don’t have to let them in. We certainly shouldn’t taunt them. It’s not as cool as an arm bar, but to keep away our modern predators, all we have to do is lock the door.

To make this a lifestyle, not a right-now-style, change to this diet in slow, sustainable steps:

  1. Take what you currently eat and try to balance it out a little more, where each meal or snack is half good carbs (fruits, veggies, and whole grains) and the other half is protein and fats. Don’t change anything else – just make a few tweaks to what you do eat. This is pretty easy, and you might feel more full for longer after you eat. Don’t change anything else for about a week.
  2. Try to eat more frequently – every 3 or so hours. Have a meal, snack, meal, snack, meal, and snack. Even if you eat a garbage selection of foods, our first goal is to just make time to eat in our busy lives. This is often the hardest part. Keep this going for about a week. You’re well on your way to making this a habit.
  3. Eating more balanced meals and snacks more frequently will have a natural “diet” effect – you’ll tend to want to eat less as you’ll be fuller longer. This helps this step, where we want to reduce our calories down a bit. This step involves more math and maybe some tracking. We cover it in depth here.
  4. Now we can start making smarter food choices. Buying higher quality foods, varying our diet.

Slow steps are what is needed. It’s not until we’ve learned the white-belt steps that we can become a yellow-belt.  We progress and go deeper into our understanding. Over a year, you will lose weight but you’ll be eating a normal diet. A diet that is healthier, simpler, and longer lasting.

Empathy For The Dieter

These diets are another in an endless line of fads that may provide short term weight loss but do so at the expense of our real goal – long term, sustainable health.  

I empathize completely. Sometimes it helps to hit the reset button. It does something to us psychologically when we make dramatic changes. Completely cut out all carbs. Do a 3 day fast. Do a coffee-only cleanse. Shave off all our hair. It’s like a jump start. It’s motivation. But that’s not how it works. Let me share one of my favorites from @impostorcomics:

Motivation is the just the spark. It’s not the wood, nor is it gasoline  As is always the case with these fad diets, the fire WILL go out. These trendy things don’t last because discipline – not what you do or don’t eat – is the most important component of a healthy life. IF and Keto and all the others are just shortcuts, and fads like these don’t teach nor encourage discipline. At least not in a meaningful way.  

When it comes to living your best life, you don’t need Keto, IF, Paleo, Raw, The Cookie Diet, Atkins, Slim Fast, or Weight Watchers. You need a plan, sustainable practices you can easily turn into habits, and the discipline to execute every damn day.  

We need less of these same voices encouraging you to be a lemming, jumping on bandwagon after bandwagon, year after year.  The answer for the best diet and wellness practices isn’t being spread by these louder voices. But the answer is there. Call it the Wellness Pyramid or whatever, I don’t care. It’s clear. It’s simple. It’s not sexy like these fads. What it is, though, is a real strategy for a better life based on years of our best evidence. It evolves, but it fundamentally remains the same.

So stop listening to the voices on social media or whatever the next way the new versions of this stuff will get spread.

Instead, there are 2 voices you should listen to – the one telling you to ignore the noise and distractions and the one telling you to keep going. My professional life goal is to make both of those voices come from within as many people’s own mind as humanly possible.

Until then: Ignore the noise and the distractions. 

Keep going.

Just trying to keep it real…

Neal Smoller, PharmD
Owner, Pharmacist, Big Mouth

Dr. Neal Smoller, Holistic Pharmacist

About Neal Smoller

Dr. Neal Smoller, PharmD, is a licensed pharmacist: and owner of Village Apothecary, an independent pharmacy in the most famous small town in America—Woodstock, NY. He’s also the host of the popular wellness podcast, The Big Mouth Pharmacist.”


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