Following a keto diet
The ketogenic diet originated as a strict, medically supervised regimen to help reduce seizures in patients — particularly children — with epilepsy. Although evidence suggests a keto diet may help some patients with other conditions like diabetes, this approach to eating must be undertaken carefully. For instance, going keto could change the way you respond to certain medications.
“There is a big difference between the keto diet as taught by internet influencers and the keto diet as used by trained medical professionals,” says Dr. Eric Westman, an associate professor at Duke University, director of the Duke Keto Medicine Clinic and author of “End Your Carb Confusion: A Simple Guide to Customize Your Carb Intake for Optimal Health.” He is based in Durham, North Carolina.
Westman emphasizes: “If you have medical problems, and especially (if you) are taking medications for diabetes or high blood pressure, do not follow a keto diet without supervision from a health professional with experience in deprescribing (tapering off) medications. The medications can become too strong on the first day of the diet change.”
It’s best to have a medical professional evaluate and advise on how to make the necessary adjustments. For individual guidance, he says, “you might be able to find a local health professional through the Society of Metabolic Health Practitioners or the Obesity Medicine Association.”
In addition, the keto diet is not recommended for certain individuals such as people who have heart disease, cancer, eating disorders, as well as children and pregnant and lactating women.
Always seek the advice of a medical professional before starting the keto diet or any diet, especially if you’re not sure about how the diet may impact your medical conditions.
Healthy keto foods and drinks
The keto diet is a high-fat, super-low-carb diet with staying power. As this diet continues to attract followers and inspire new versions and spinoffs, it’s clear that some keto-friendly foods are healthier than others. And don’t forget fluids: You can choose healthier, keto-friendly beverages, too.
Keto promotes weight loss by inducing your body to burn stored fat, instead of glucose from carbs, for energy. Here are some key foods, drinks and tips for minding your health and maintaining good nutrition and hydration while watching your weight on keto.
Whole foods/real foods
Focusing on whole foods is the healthiest way to go when following keto, says Molly Devine, a Durham, North Carolina-based registered dietitian, nutrition and cookbook author and founder of MSD Nutrition Consulting. That includes limiting highly processed foods with unhealthy ingredients — even those labeled as keto products — and choosing more natural versions.
“It doesn’t mean that you’re making everything from scratch,” Devine says. “You can lean heavily on some convenience things.”
Rotisserie chicken sold in grocery stores, for instance, is a great choice for busy parents aiming for healthy meals. Many stores now sell it pre-pulled, she notes. Canned tuna, already-boiled eggs and bottled, oil-based pesto sauce can be ready to serve in a few seconds or minutes. Devine likes to throw some chicken thighs in her slow cooker with a tikka masala simmer sauce.
“It’s lots of spices, no sugar added, fast and simple,” she says. “I didn’t spend all day long cooking that.”
One rule of thumb is assessing whole foods before meal prep. “When I think of real food — did it come out of the ground looking like that? A chicken is a chicken, a plant is a plant, a nut is a nut,” Devine says.
That’s versus products that come in a box — or a candy wrapper — with a long list of ingredients, or so-called ‘dirty keto‘ foods.
“Even if the macronutrients are ketogenic, that food still isn’t healthy,” Devine says.
Avocados are the No. 1 food item for keto-friendly diets, says Lolita Carrico, a certified nutritionist, chef and founder of ketology.net, which focuses on a keto lifestyle for women over 40 but also offers plenty of tips for anyone interested in keto.
Avocados are rich in monounsaturated fat, a healthy type of fat when eaten in moderation. This fruit is also a great source of fiber and a wide array of vitamins and minerals. Eating avocados helps you feel full — which is half the battle when you’re trying to lose weight.
Fatty, cold-water fish, such as salmon, tuna and mackerel, are good sources of healthy fat.
Salmon is both versatile and tough, Carrico says. It can withstand the grill without flaking out, and it can be used in multiple ways. For instance, you can cube salmon for a stir-fry or serve it raw in poke bowls with high-quality veggies.
Emilie Vandenberg, a registered dietitian at the Ohio State University Wexner Medical Center in Columbus, recommends making a tuna salad with mayonnaise, avocado and mustard served with vegetables.
And while fresh foods are typically best, there’s a lot to be said for canned fish when following the keto diet. Canned fish varieties also provide heart-healthy, unsaturated fats rich in omega-3 fatty acids. Another bonus: They’re cheap and convenient.
Sardines and anchovies are excellent sources of omega-3, Devine says, though people tend not to down anchovies as a main course. However, anchovies are among select foods thought to benefit brain health, and you can always use them to top a keto-friendly, cauliflower-crust pizza.
Other healthy fish choices? “Canned tuna and canned mackerel are really good,” Devine says.
You can experience a bread-like texture without actually eating bread. Portobello mushrooms can replace bread or buns, says Vahista Ussery, a Fort Worth, Texas-based registered dietitian nutritionist, chef and founder of To Taste, a culinary nutrition consulting and education company.
Portobello mushrooms have a somewhat beefy flavor, making them a good swap for meat as well. They’re also a rich source of minerals, such as potassium, copper and selenium, as well as essential B vitamins. In general, mushrooms are low in net carbs and provide a good amount of protein.
Ussery herself isn’t a big keto fan overall. “The keto diet is not easy,” she says. “It requires research, dedication and sacrifice. If you follow the keto diet correctly, you will lose weight — but ask yourself if you can maintain this diet in the long run.”
She also has several concerns about keto falling short as a well-balanced diet. “The keto diet restricts many foods we know to be healthy and consumed by the world’s longest-lived populations,” she says. “Whole grains, beans, fruit and starchy vegetables like sweet potatoes are all healthy and promote longevity. To me, that’s a huge red flag.”
If you’re determined to try the keto diet, Ussery suggests opting for foods that make the diet as healthy as possible — again, that’s whole foods that have been minimally processed.
Grilled, pan-seared or broiled: It’s your preference when it comes to grass-fed beef. Grass-fed beef has less fat, fewer calories and higher levels of omega-3s than standard, grain-fed beef.
“The most important thing is to make sure you’re adding high-quality fat to keep it moist,” Carrico says. “The lovely thing about a keto lifestyle is you can cook your favorite foods the way you always have — it’s just what you eat with it.”
So instead of steak and potatoes, or steak and rice, she says, sub in keto-appropriate side dishes, such as cauliflower rice or roasted asparagus.
Veggies belong to a healthy keto diet, but there are some caveats.
Compared to fruits, “there are more choices with vegetables, but they do need to be low-carb, non-starchy ones,” Ussery says. “Skip the potatoes — including sweet potatoes — and corn, and load up on leafy greens, broccoli, asparagus, zucchini, cauliflower and more.”
Radishes and tomatoes are also low-carb produce.
“Vegetables should accompany all meals to ensure people on keto are getting plant-based nutrients and phytochemicals to help fight inflammation and prevent disease,” Ussery advises.
You have multiple options for preparing keto-friendly vegetables: “Roast, stir-fry or sauté them in healthy oils, and don’t forget about spices for flavor,” she says.
The keto movement embraces creative takes on familiar wheat-based, carb-laden fettuccine or linguine.
“Pasta substitutes include shirataki noodles, spaghetti squash and zucchini noodles,” Westman notes.
Using pasta adaptations like these gives you an extra plant-based health benefit. For instance, shirataki noodles, derived from Asian konjac yam, can serve as a low-carb, low-calorie, fiber-rich side dish.
Cauliflower rice, cauliflower pizza crust, cauliflower ice cream — cauliflower food hacks have almost become a keto cliché.
“Cauliflower gets such a bad rap as a potato substitute, but I love making mashed cauliflower,” Carrico says. “It tastes so much better to me than mashed potatoes, now that I’ve been doing it for a while.”
You can mash, roast or even rice cauliflower in a food processor, she adds, or buy riced cauliflower at the grocery store.
“The ketogenic diet is often thought of as a low-carb, high-protein diet, but it’s actually a high-fat, low-carb, moderate-protein diet,” Vandenberg explains. “Eating too much protein can prevent you from entering or maintaining ketosis.”
To align with the principles of the standard ketogenic diet, you need to keep your protein intake at or below 6% of total calories. Carbohydrate intake should be at just 4%, and fat intake should account for 90% of total calories to meet the guidelines of a traditional ketogenic diet.
However, your body needs the macronutrient protein for essential functions like building muscle. This means you need to include some protein, and lean sources are generally best as they are lower in saturated fat, which has been linked with heart disease.
Poultry, seafood, eggs, dairy and yogurt are all leaner protein options that can be part of the keto diet. Lean cuts of red meat can be used in moderation, and you should avoid fatty protein sources, such as processed or fried meats. Seeds like sunflower seeds and pumpkin seeds are good anti-inflammatory sources, Devine says, and they’re tasty to sprinkle on salads. Nuts also provide protein, she notes, but it’s easy to overeat them — they’re calorie dense — so she tends to use them more as a garnish.
Planning a healthy, keto-friendly, low-carb meal can also be simple.
“There’s a protein, there’s a non-starchy vegetable and there’s a good, healthy fat on my plate,” Devine says. So, that could be salmon, a non-starchy veggie like Brussels sprouts and a big side salad.
Devine’s general advice on proteins: Keep a good balance of heart-healthy fats to the saturated fats in animal products.
Although some keto proponents recommend skin-on chicken thighs as a higher-fat poultry source, Carrico prefers to serve skinless chicken breasts. Or you could just cook the entire chicken.
“Weeknight skillet roast chicken with lemon-herb pan sauce” is a keto fan favorite, according to the recipe creators at America’s Test Kitchen.
Nuts and nut butters
Walnuts and pecans are good nut choices, especially for older adults.
“They’re the lowest carb and have a good healthy-fat profile, as well,” Carrico explains.
Similarly, some nut butters are better than others.
“I would stay away from peanut butter because peanuts are a little higher on the carb side,” she says, adding that there are some concerns about pesticides sprayed on peanuts growing in the field. “Almond or pecan butter is great,” she adds. “I make almond butter at home — you literally just blend it into a natural nut butter.”
Some companies now make “amazing, keto-friendly nut butters that don’t have sugar,” Carrico says. “The main thing is: If you’re buying a nut butter at the store, read the label because they usually add sugar and you have to find no-sugar-added versions.”
Fruits are one of the restricted food groups on keto. But berries, featured in many diets, including DASH and MIND, can be a keto-compatible fruit option, provided you keep portions small, Vandenberg says. “Small portions, about ½ cup of raspberries, blackberries or strawberries, can be incorporated.”
Ussery agrees that when it comes to fruit on the keto diet, “berries are the best choice, especially strawberries, raspberries and blackberries. Luckily, they are considered some of the healthiest fruits with their high amounts of phytochemicals.”
Phytochemicals, which give fruits and veggies their vibrant colors, are powerful antioxidants that can help protect your cells against damage and could reduce the risk of chronic diseases, such as diabetes, cancer and dementia.
Carrico suggests combining nuts and berries for a satisfying, high-antioxidant, fiber-rich keto snack.
However, for strict keto adherents, berries are a no-go, Westman says. “Unless you are young, extremely active or have a metabolism that doesn’t ‘need keto,’ there are no fruits or berries on a ‘prescription-strength’ keto diet — one that works for everyone with obesity, metabolic syndrome or diabetes.”
Kale and spinach
Healthy plant foods and the keto diet can go hand in hand.
“Although a lot of people think keto is beef and butter, fiber in the form of a salad is very beneficial,” Carrico says. “So I’ll usually have a huge salad every day with kale and spinach.”
Combining these leafy greens offers a great mix of nutrients. Kale is particularly rich in calcium and vitamins C and K. At the same time, spinach is a super source of minerals, such as iron, magnesium and potassium, as well as vitamins A and E.
Butter lettuce can hold a burger like a bun or act as a sandwich wrap, making it keto-convenient. And of course, you can build a salad around it.
The two main types of butter lettuce (or butterhead lettuce) are bibb and Boston lettuce, featuring tender leaves with a delicate flavor. Butter lettuce is an excellent source of dietary fiber, and it contains a variety of healthy vitamins and minerals.
Do you cringe at the idea of even smelling, much less swallowing, Brussels sprouts? If so, you’re not alone.
“I know, but they’re really good if you cook them right,” says Carrico, who’s a “huge fan” of the pungent, cruciferous veggie.
To encourage reluctant keto adherents to give them a try, Carrico offers a recipe for garlic-Parmesan smashed Brussels sprouts. “Even my children like them,” she swears. You’ll just need these ingredients:
— 1 pound trimmed Brussels sprouts.
— 2 tablespoons avocado oil.
— 2 teaspoons garlic powder.
— 1 teaspoon crushed red pepper.
— 1/4 cup shaved Parmesan.
Follow the simple recipe instructions on boiling the Brussels sprouts, crushing them into patties, then seasoning them with the avocado oil, garlic powder and crushed red pepper before roasting and finally sprinkling on the Parmesan cheese and briefly broiling.
If you’re following a keto diet, skip the whole milk, the skim milk and the ‘light’ yogurt in the dairy aisle. Instead, add lower-carb items like plain Greek yogurt and butter to your grocery cart.
“As far as dairy goes, if I’m having coffee, I’ll definitely have a splash of heavy whipping cream, because full fat is very important,” Carrico says, while noting that you don’t necessarily have to douse your coffee in cream.
Butter and ghee — which is simply clarified butter — are essentially carb-free. Many types of cheese work for keto, including Brie, cheddar, Swiss, provolone, mozzarella and Monterey Jack.
Yogurt and kefir
Rich in probiotics, yogurt and kefir are probably the best dairy options for keto, Ussery says. Both are types of fermented foods, a known good source for probiotics. If you’re unfamiliar with kefir, it’s a fermented milk made from kefir grains. Probiotics are the “good” bacteria in your gut. Having a normal balance of probiotics is important for gastrointestinal health.
Keep in mind that full-fat yogurt may contain some carbohydrates due to the natural lactose content of milk, Ussery adds. “For people following very strict ketogenic diets, remaining conscientious of sources like this is important.”
When it comes to what to drink, water is your best bet on the keto diet. It has no calories and no carbs — you can’t go wrong with water.
“You need to stay hydrated,” Devine says. “That’s a big piece to avoiding some of those classic keto dehydration (problems) while people are first adapting to the keto diet.”
As your body burns fat, the liver creates ketones to use for energy. These ketones have a diuretic effect, making you urinate more frequently.
The so-called keto flu – which isn’t actually the flu but can produce symptoms reminiscent of influenza as your body adjusts to the keto diet – can lead to diarrhea, nausea, vomiting, fatigue and headache.
You can also add a little effervescence to water and still keep it keto-friendly.
“There are umpteen brands of seltzer water out there now,” Devine notes. And they “count” just as much toward hydration as plain water. Electrolyte drinks are fine, too. “You just want to look for the ones that don’t have added sugar,” she says.
Tea offers a variety of flavor options. A hot cup of herbal tea is a great afternoon or anytime drink while you’re doing keto, especially in the colder months.
Low-calorie favorites, such as chamomile tea and green tea, are soothing ways to stay hydrated. If you’re looking for something stronger, black tea is fine as long as it’s unsweetened. Iced tea comes with the same caveat. Unsweetened iced tea is fine for keto, though many bottled teas sold in stores or served by restaurants are already sweetened.
You can compromise by using keto-friendly sweeteners like stevia or Splenda. Squeezing in fresh lemon juice can also add a burst of flavor to your tea.
Popular keto-adapted foods include the chaffle — a cheese-and-egg waffle. They’re easy to make with an inexpensive mini-waffle maker, and you can add a flavor boost with a dash of cinnamon or cocoa powder.
“Cheese is another healthful option,” Ussery says. “While cheese is high in saturated fat, it does contain nutritional benefits. Avoid processed cheese, and look for natural kinds like cheddar or Parmesan.”
Certain plant oils — for cooking, dressings and flavoring — play a big part in keto meals and snacks. Coconut, avocado and extra-virgin olive oil are prime sources for healthy fat, Carrico says.
Many keto followers swear by MCT oil, a manufactured combination of processed palm oil and coconut oil. MCT stands for medium-chain triglyceride, a compound made of specific fat molecules. Carrico uses MCT in her salad dressing and coffee.
Ussery says, “While I hesitate to recommend coconut oil as a predominant oil for a traditional eating pattern, MCT oils actually help promote ketosis.”
Because it’s more easily absorbed than other oils, MCT may be a good choice for people who have difficulty with fat absorption, such as those with irritable bowel syndrome and other digestive conditions.
With the keto diet, “any non-sugar sweetener is fine, but they are counted in the total carb calculation for the day,” Westman points out.
In terms of flavor, Carrico recommends allulose and monk fruit sweeteners as natural, plant-based alternatives to sugar. Both taste more like sugar and are better overall than stevia, Carrico finds.
Allulose, which is found in select plant foods such as kiwi, figs and raisins, has few carbs and essentially zero calories. Monk fruit sweetener, a powder derived from a green melon that grows in parts of Asia, is carb- and calorie-free.
For her part, Ussery is not really a sweetener enthusiast.
“I’m not a fan of artificial sweeteners used for diabetics as there are still some questions with long-term safety,” she says. “If I had to recommend alternative sweeteners, I would say natural stevia extract or monk fruit, if you can find it. One of my concerns is that alternative sweeteners may alter people’s taste preference for sweet foods, leading to cravings for more. These sweeteners are so sweet, (they) can make natural foods — like fruit — seem less sweet and less appealing.”
Eggs are a keto staple. High in protein, eggs lend themselves to keto-friendly breakfasts such as egg-stuffed avocado, egg-and-cheese muffins and salmon omelets.
“Eggs are a keto must-have food,” Carrico says. She prefers pasture-raised eggs, which according to one 2010 study conducted at Pennsylvania State University, have significantly higher levels of omega-3 fatty acids and vitamin E than regular free-range eggs.
Primed with butter, MCT or coconut oil, bulletproof coffee — a keto favorite — can be a satisfying, energizing, fat-supplying breakfast in itself. But don’t treat it as a side beverage to accompany a meal of bacon and eggs. If you’re trying to lose weight on keto, calories still count.
“Bulletproof coffee is fine, but it’s not free,” Devine says.
Laden with calories, the beverage is really more like a meal replacement, she explains. Although people may believe they’re fasting in the morning by having bulletproof coffee alone, she says, that isn’t the case. If you’re taking in 500 calories and upward from the added fat, that isn’t fasting.
The same goes for commercial products like keto desserts.
“I have my keto ice cream every night” is something Devine often hears from keto fans. However, “look at the box, and it’s 300 calories per serving,” she notes. “If you’re consuming 300 extra calories every single night after your meal, that’s why you’re not losing weight. No one should be doing that all the time.”
Instead, think of desserts as treats to have sparingly for special occasions, such as birthdays or holidays, she advises.
Healthy keto foods
Going keto? Put these healthy staples on your grocery list:
— Fatty fish, such as salmon.
— Portobello mushrooms.
— Grass-fed meats.
— Non-starchy veggies.
— Pasta substitutes, such as shirataki and zucchini noodles.
— Leaner protein, such as seafood and eggs.
— Nuts and nut butters.
— Kale and spinach.
— Butter lettuce.
— Brussels sprouts.
— Full-fat dairy, such as butter.
— Yogurt and kefir.
— Water varieties, such as seltzer and electrolyte drinks.
— Herbal tea.
— Chaffles, or waffles made with eggs and cheese.
— Coconut, avocado, MCT and extra-virgin olive oil.
— Allulose and monk fruit sweeteners.
— Pasture-raised eggs.
Keep these keto tips in mind:
— Make desserts an occasional treat, not a daily habit.
— Select leaner protein sources.
— Hydrate adequately.
— Substitute foods creatively.
— Consider calories; they still count.
— Read keto-friendly labels carefully; watch out for added sugars.
— Consult your doctor and dietitian.
More from U.S. News
11 Healthy Food Swaps to Lose Weight
Tips to Succeed on the Keto Diet
A Day’s Worth of Meals on the Keto Diet
Best Foods to Eat on the Keto Diet originally appeared on usnews.com
Update 02/22/23: This story was previously published at an earlier date and has been updated with new information.