Dangers of Zero-Carb Diets, IV: Kidney Stones

Kidney stones are a frequent occurrence on the ketogenic diet for epilepsy. [1, 2, 3] About 1 in 20 children on the ketogenic diet develop kidney stones per year, compared with one in several thousand among the general population. [4] On children who follow the ketogenic diet for six years, the incidence of kidney stones is about 25% [5].

A 100-fold odds ratio is hardly ever seen in medicine. There must be some fundamental cause of kidney stones that is dramatically promoted by clinical ketogenic diets.

Just over half of ketogenic diet kidney stones are composed of uric acid and just under half of calcium oxalate mixed with calcium phosphate or uric acid. Among the general public, about 85% of stones are calcium oxalate mixes and about 10% are uric acid.  So, roughly speaking, uric acid kidney stones are 500-fold more frequent on the ketogenic diet and calcium oxalate stones are 50-fold more frequent.

Causes are Poorly Understood

In the nephrology literature, kidney stones are a rather mysterious condition.

Wikipedia has a summary of the reasons offered in the literature for high stone formation on the ketogenic diet [4]:

Kidney stone formation (nephrolithiasis) is associated with the diet for four reasons:

  • Excess calcium in the urine (hypercalciuria) occurs due to increased bone demineralisation with acidosis. Bones are mainly composed of calcium phosphate. The phosphate reacts with the acid, and the calcium is excreted by the kidneys.
  • Hypocitraturia: the urine has an abnormally low concentration of citrate, which normally helps to dissolve free calcium.
  • The urine has a low pH, which stops uric acid from dissolving, leading to crystals that act as a nidus for calcium stone formation.
  • Many institutions traditionally restricted the water intake of patients on the diet to 80% of normal daily needs; this practice is no longer encouraged.

These are not satisfying explanations. The last three factors focus on the solubility of uric acid or calcium in the urine; the first on availability of calcium, one of the most abundant minerals in the body.

There is no consideration of the sources of uric acid, oxalate, or calcium phosphate.

Two of the factors focus on urine acidity, but alkalinizing diets have only a modest effect on stone formation. In the Health Professionals Study and Nurses Health Study I and II, covering about 240,000 health professionals, people with the lowest scores for a DASH-style diet (an alkalinizing diet high in fruits, vegetables, nuts, and legumes) had a kidney stone risk less than double that of those with the highest DASH-style scores. [6]

On ketogenic diets specifically, supplementation with potassium citrate to alkalinize the urine and provide citrate reduced the stone formation rate by a factor of 3. [3] They were still more than 30-fold more frequent than in the general population.

It seems the medical community is still unaware of some primary causes of stone formation.

Uric Acid Production

One difference between a ketogenic (or zero-carb) diet and a normal diet is the high rate of protein metabolism. If both glucose and ketones are generated from protein, then over 150 g protein per day is consumed in gluconeogenesis and ketogenesis. This releases a substantial amount of nitrogen. While urea is the main pathway for nitrogen disposal, uric acid is the excretion pathway for 1% to 3% of nitrogen. [7]

This suggests that ketogenic dieters produce an extra 1 to 3 g/day uric acid from protein metabolism. A normal person excretes about 0.6 g/day. [8]

In addition to kidney stones, excess uric acid production may lead to gout. Some Atkins and low-carb Paleo dieters have contracted gout.

Oxalate Production

Our last post (on scurvy) argued that very low-carb dieters are probably inefficient at recycling vitamin C from its oxidized form, dehydroascorbic acid or DHAA.

If DHAA is not getting recycled into vitamin C, then it is being degraded. Here is its degradation pathway:

The degradation of vitamin C in mammals is initiated by the hydrolysis of dehydroascorbate to 2,3-diketo-l-gulonate, which is spontaneously degraded to oxalate, CO(2) and l-erythrulose. [9]

Oxalate is a waste material that has to be excreted in the kidneys. Vitamin C degradation is a major – in infections, probably the largest – source of oxalate in the kidneys:

Blood oxalate derives from diet, degradation of ascorbate, and production by the liver and erythrocytes. [10]

Since the loss rate from vitamin C degradation can reach 100 g/day in severe infections, and most of that mass is excreted as oxalate, it is apparent that a very low-carb dieter who has active infections, as did I and KM in the scurvy post, or some other oxidizing stress such as injury or cancer, may easily excrete grams of oxalate per day, with the amount limited by vitamin C intake.

Dehydration and Loss of Electrolytes

Excretion of oxalate consumes both electrolytes, primarily salt, and water:

In mammals, oxalate is a terminal metabolite that must be excreted or sequestered. The kidneys are the primary route of excretion and the site of oxalate’s only known function. Oxalate stimulates the uptake of chloride, water, and sodium by the proximal tubule through the exchange of oxalate for sulfate or chloride via the solute carrier SLC26A6. [10]

Salt and water are also needed by the kidneys to excrete urea and uric acid.

Personally, I found that my salt needs increased dramatically on a zero-carb diet. I needed at least a teaspoon per day of salt when zero-carbing, compared to less than a quarter-teaspoon when eating carbs.

As a result of loss of salt and water, low-carb dieters tend to become dehydrated. This is also a widely-observed side effect on ketogenic diets.

We’ve all seen what happens to urine when we’re dehydrated: it becomes colorful due to high concentrations of dissolved compounds.

As urine becomes saturated, it no longer possible for uric acid and oxalate to dissolve. They precipitate out and initial deposits nucleate further deposits to form kidney stones.

Polyunsaturated Fats and Kidney Stones

That brings us to another factor that promotes kidney stones: high omega-3 polyunsaturated fat consumption.

Here’s the data:

Older women (NHS I) in the highest quintile of EPA and DHA intake had a multivariate relative risk of 1.28 (95% confidence interval, 1.04 to 1.56; P for trend = 0.04) of stone formation compared with women in the lowest quintile. [11]

Eating omega-3 fats promotes calcium oxalate kidney stones about as much as eating oxalate. The top quintile of dietary oxalate intake has a relative risk of 1.22. [12]  (The top dietary source of oxalate is spinach, by the way.)

So what about EPA and DHA promotes kidney stone formation?  A clue comes from julianne of Julianne’s Paleo & Zone Nutrition Blog; she made a very interesting comment:

A few years ago I started taking a high dose of Omega 3, because of joint inflammation, and other issues. This made big difference for about 3 months, then seemed to not work any more. I talked to a nutritionist friend and she pointed out that according to Andrew Stoll (The Omega 3 Connection) you must take 1000 mg vit C and 500 iu vit E daily or the omega 3 becomes oxidised in your body (cell membranes) and ineffective. I started taking both and in days was back to the original anti-inflammatory effectiveness of omega 3. I have since talked to others about this – for example a psychiatrist whose clients did well on omega 3 for 3 months and then it became ineffective.

Paleo advice from many is to consume a high dose of omega 3, and at the same time reduce carbs. I am wondering if there are people suffering vit C depletion as a result of increased omega 3 consumption as well as too low carbs?

EPA and DHA have a lot of fragile carbon double bonds – 5 and 6 respectively – and are easily oxidized. It’s quite plausible that this lipid peroxidation can lead to oxidation and degradation of vitamin C.

If so, then higher EPA and DHA consumption would increase the flux of oxalate through the kidneys and raise the risk of calcium oxalate stones. It makes sense that the effect is strongest in the elderly, who tend to have the worst antioxidant status.

What Does This Tell Us About the Cause of Stones in the General Population?

Since most kidney stones afflicting the general public are calcium oxalate stones, it seems likely that vitamin C degradation may be the major source of raw material for kidney stones.

If so, then the risk of kidney stones can be greatly reduced by dietary and nutritional steps.

First, the rate of oxidation can be slowed by higher intake of antioxidants such as:

  • Glutathione and precursors such as N-acetylcysteine;
  • Selenium for glutathione peroxidase;
  • Zinc and copper for superoxide dismutase;
  • Coenzyme Q10 for lipid protection;
  • Alpha lipoid acid;
  • Colorful vegetables and berries.

Vitamin C supplementation has mixed effects: its antioxidant effect is beneficial but its degradation is harmful.

Second, electrolyte and water consumption are important. Salt is especially important.

Finally, alkalinizing compounds like lemon juice or other citrate sources can increase the solubility of uric acid.

Conclusion

Zero-carb dieters are at risk for

  • Excess renal oxalate from failure to recycle vitamin C;
  • Excess renal uric acid from disposal of nitrogen products of gluconeogenesis and ketogenesis;
  • Salt and other electrolyte deficiencies from excretion of oxalate, urea and uric acid; and
  • Dehydration.

These four conditions dramatically elevate the risk of kidney stones.

To remedy these deficiencies, we recommend that everyone who fasts or who follows a zero-carb diet obtain dietary and supplemental antioxidants, eat salt and other electrolytes, and drink lots of water.

Also, unless there is a therapeutic reason to restrict carbohydrates, it is best to obtain about 20% of calories from carbs in order to relieve the need to manufacture glucose and ketones from protein. This will substantially reduce uric acid excretion. If it also reduces vitamin C degradation rates, as we argued in our last post, then it will substantially reduce oxalate excretion as well.

Related Posts

Other posts in this series:

  1. Dangers of Zero-Carb Diets, I: Can There Be a Carbohydrate Deficiency? Nov 10, 2010.
  2. Dangers of Zero-Carb Diets, II: Mucus Deficiency and Gastrointestinal Cancers A Nov 15, 2010.
  3. Danger of Zero-Carb Diets III: Scurvy Nov 20, 2010.

References

[1] Furth SL et al. Risk factors for urolithiasis in children on the ketogenic diet. Pediatr Nephrol. 2000 Nov;15(1-2):125-8. http://pmid.us/11095028.

[2] Herzberg GZ et al. Urolithiasis associated with the ketogenic diet. J Pediatr. 1990 Nov;117(5):743-5. http://pmid.us/2231206.

[3] Sampath A et al. Kidney stones and the ketogenic diet: risk factors and prevention. J Child Neurol. 2007 Apr;22(4):375-8. http://pmid.us/17621514.

[4] “Ketogenic diet,” Wikipedia, http://en.wikipedia.org/wiki/Ketogenic_diet.

[5] Groesbeck DK et al. Long-term use of the ketogenic diet. Dev Med Child Neurol. 2006 Dec;48(12):978-81. http://pmid.us/17109786.

[6] Taylor EN et al. DASH-style diet associates with reduced risk for kidney stones. J Am Soc Nephrol. 2009 Oct;20(10):2253-9. http://pmid.us/19679672.

[7] Gutman AB. Significance of uric acid as a nitrogenous waste in vertebrate evolution. Arthritis Rheum. 1965 Oct;8(5):614-26. http://pmid.us/5892984.

[8] Boyle JA et al. Serum uric acid levels in normal pregnancy with observations on the renal excretion of urate in pregnancy. J Clin Pathol. 1966 Sep;19(5):501-3. http://pmid.us/5919366.

[9] Linster CL, Van Schaftingen E. Vitamin C. Biosynthesis, recycling and degradation in mammals. FEBS J. 2007 Jan;274(1):1-22. http://pmid.us/17222174.

[10] Marengo SR, Romani AM. Oxalate in renal stone disease: the terminal metabolite that just won’t go away. Nat Clin Pract Nephrol. 2008 Jul;4(7):368-77. http://pmid.us/18523430.

[11] Taylor EN et al. Fatty acid intake and incident nephrolithiasis. Am J Kidney Dis. 2005 Feb;45(2):267-74. http://pmid.us/15685503.

[12] Taylor EN, Curhan GC. Oxalate intake and the risk for nephrolithiasis. J Am Soc Nephrol. 2007 Jul;18(7):2198-204. http://pmid.us/17538185.

Leave a comment ?

109 Comments.

  1. Hi Lars,

    No, I don’t think so. 10 months is a long time.

  2. About Vitamin C and oxalate, that is quite interesting story.
    First, it was speculation to bring down Linus Pauling based on theory. It was never confirmed that C actually can lead to kidney stones and there are bunch of reports that it can actually cure them.

    For some reason that pathway doesn’t seem to happen in vivo. Or, if it happen, oxalates are stil in normal range.
    Calcium stones are the ones problematic so supplementing with Magnesium is good way to prevent it as Mg has higher affinity to oxalate then Ca.
    Also, it seems that reduced pH of the urine due to the DHAA filtering might change the scenario.

    I am aware of only 1 known case after extensive research – In Riordan protocol (cancer threatment with huge amounts of IV vitamin C and K3) there was 1 man who developed kidney stones. I remember that the range used was around 150g IV per day which equals to around 1kg of oral C (since absorption is 10-15%). Given that Riordan threated countless people in his clinic, I highly doubt kidney stones are of concern for even megadosers. My entire family and bunch of friends are using ~10g C per day for entire year without any problems so far. One of my friends has kidney sand (if that is correct therm) and his sympthoms dimished on megadose.

    Other then that I recommend exelent book:
    Herb, nutrient, and drug interactions: clinical implications and therapeutic strategies

    The charpter about C is extensive and it covers all details about kidney stones.

    In other book, “Herbs and natural supplements” in Vitamin C chapter authors say:

    “Although widely assumed to increase the risk of kidney stones, recent studies suggest high-dose vitamin C supplementation does not significantly increase this risk. In 1994, researchers discovered that vitamin C (in doses as high as 10 gftiay) does not increase the amount of oxalate produced in the body (Wandzilaket al
    1994). Instead, urine testing used to detect oxalate levels were found to actually be detecting oxalate formed by the conversion of ascorbate during the test procedure. As such, increased urine oxalate as tested by this method does not genuinely represent in vivo oxalate levels when ascorbate is involved. Two prospective studies
    of over 85,000 women and 45,000 men found that doses ranging from less than 250 mg/day to more than 1500 mg/day taken over 6-14 years did not correlate with occurrence of kidney stones (Curhan et al 1996,1999).”

    In “Relation of serum ascorbic acid to serum vitamin B12, serum ferritin, and kidney stones in US adults.”

    “Serum ascorbic acid levels were not associated with decreased serum vitamin B12 levels (or indicators of vitamin B12 deficiency), prevalence of kidney stones, serum ferritin levels, or-among men-prevalence of elevated serum ferritin levels.”

    From Andrew Saul (doctoryourself.com)
    “Ascorbate (the active ion in vitamin C) does increase the body’s production of oxalate. Yet, in practice, vitamin C does not increase oxalate stone formation.”

  3. I would be interested to see a break out analysis of the dietary contents for the epileptic children who developed kidney stones. The “shakes” that the clinical programs provide are full of hydrogenated oils and corn syrup. I would not be surprised if such an analysis showed that kids who are on the modified Atkins diet did NOT develop kidney stones.

  4. Hello and welcome back from the Ancestral Symposium. I was looking into the causes of pseudo gout, which I learned a couple days back that I’ve got it. I’m rather concerned as I am only 37 years old and have been following a low carb diet since 2009, but added carbs back in Feb 2011 since discovering Perfect Health Diet. I am rather surprised I have pseudo gout as I always thought I eat very healthily, as opposed to standard westernised diet. Do you think my pre-low carb dietary habit could have somehow caused the pseudo gout? I don’t think I ate that much meat anyway,even now, although I don’t weigh, but I am quite sure of that.

    I have just been out of the hospital (for meals, I told them no wheat for me please and they brought me bread for breakfast by mistake–it’s for other patients– the horror!), and am given steroids as medication. It’s working pretty well. What would you recommend I improve on my diet?

    Thank you so much in advance!

  5. Hi Wati,

    I don’t know if the very low carb might have contributed. Hemochromatosis (excess iron) is considered a cause, has that been checked out?

    A search on “pseudogout diet” (http://www.ncbi.nlm.nih.gov/pubmed?term=pseudogout%20diet) yields only 9 papers. There might be a genetic basis (http://www.ncbi.nlm.nih.gov/pubmed/168817), the ANKH gene is implicated.

    The most useful paper is this one: http://www.ncbi.nlm.nih.gov/pubmed/18667063. Gitelman syndrome, an inherited condition affecting 1% of Caucasians, seems to cause early onset pseudogout. It looks like low potassium and low magnesium induce the joint crystals.

    Since low potassium is almost universal on very low carb diets, I’d look at that as the most likely dietary contributor. Bananas, potatoes, tomatoes are good sources. Eat lots of vegetables. Also, supplement with magnesium and consider using some NoSalt (potassium rich salt, tastes lousy) on foods.

    As a calcification disease, I’d also make sure I was getting plenty of K2, not too much D, and balanced D and A. I’d avoid phosphorus – no colas.

    Best, Paul

  6. Hi Paul,

    Thank so much for the swift response. Much appreciated. They did a blood and pus test (my right knee was swelling on day 2 and it hurt like mad) to look for certain type of bacteria and/or crystals to determine what kind of bone disease I have (plus other ailment if any) and to determine the proper medication based on the results. They even did an MRI. But in all they didn’t say anything about excess calcium.

    Thank you for the dietary and supplementation recommendation. I will certainly eat them more from now on. And I certainly need to start investigating my family bone health history!

    Just for the record, I have never drunk coke or sugary beverages for more than a decade, never been overweight but underweight (I was a low-calorie vegetarian prior to low carb for 10 years–lots of omega 6 for sure).

    Cheers
    Wati from Tokyo, Japan

  7. Correction: Sorry I meant to say… didn’t mention anything about excess iron, not calcium.

    Wati

  8. Hi Paul,

    I purchased your book a couple of weeks ago and began implementing the system right away. I’m coming from a very low carb diet (past two years) so it is so easy and fun to have mashed potatoes and french fries made with coconut oil.

    A few months ago I was diagnosed with a kidney stone that is too large to pass, so it is being monitored. I was wondering if there is anything I can do that might shrink an existing kidney stone.

    Thanks for all of your great work.

    Larry

  9. Hi Larry,

    The most effective remedy is citrate and water. So drink lots of water mixed with lemon juice.

    Vitamin C will probably help too. Antioxidants, like glutathione, selenium, zinc, copper, etc will help prevent new oxalate formation and accretion of the stone. Salt and other electrolytes (balanced with potassium) will also help excretion.

    Best of luck!

    Paul

  10. Hi Paul:
    I was recently diagnosed with Kidney disease.
    I also suffer from depression (bipolar) and am on lithium, which I believe has caused my weight gain. I am now overweight, and am always tired.
    My doctor also told me that I have a low thyroid.

    Paul, I am very concerned about my diagnosis of kidney disease. I can function, however, am tired all the time, and feel pain in my body.
    Paul, would the Paleo diet help my ailments.

    A response back from you would be great, as to the foods that I should be eating to help with my kidneys to function properly,
    Thanks Paul,
    Fia

  11. Hi Fia,

    A well-designed Paleo diet will help almost any condition, but especially in your case you need a version like ours, which is higher in carbs and lower in protein. Low-carb and high-protein would not be good in kidney disease.

    You should look at my latest Around the Web post, http://perfecthealthdiet.com/?p=5714, which has a few items on depression. Depression is caused by immune activity, usually in response to infection. In bipolar there is usually a genetic component, but generally genes are not determinative: it is the combination of genes and infections which produce the result.

    Lithium distorts the immune system and improves bipolar in most cases but can aggravate some infections. So you can’t automatically assume it will help you just because it is a standard treatment. You have to form your own judgment. Also, sometimes diagnoses like bipolar are questionable. Many conditions with different causes have a lot of symptomatic overlap, especially where the brain is concerned, so having symptoms that match up with bipolar doesn’t necessarily mean you have the same problems as other bipolar patients.

    For foods to eat, look at our food plate, http://perfecthealthdiet.com/?page_id=8.

    Best, Paul

  12. Paul:
    Thank you for your response.
    You mention to have more carbs, so more carbs in addition to sweet potatoes, and rice? Also Paul, is there any other information that you know of, to combat possible ramifications of kidney disease?
    Thanks,
    Fia

  13. Hi Fia,

    “Kidney disease” is a rather broad category. I don’t really want to get into medical advice, especially when I don’t know the specific condition. Some general principles: eating citric acid, eg from lemon juice or other citrus fruits, helps the kidney excrete minerals; so does adequate salt, water, and potassium (from vegetables). Vitamin D/A/K2 are helpful to normalize immune function. Infections should be diagnosed and addressed. Kidneys have a role in gluconeogenesis and blood sugar regulation so blood sugar should be monitored. Kidneys have a role in calcium and vitamin D metastasis so you should monitor calcium and 25OHD/1,25D levels. But really, you should focus on optimizing diet as in our book and working with your doctor to track down specific problems and causes.

  14. Paul,
    Do you know if the Inuit suffer from kidney stone, gout, and all the rest, in a larger than average degree? Do they have a high mortality due to compromised immune systems, etc?

  15. Need input - Elevated BUN, urine uric acid - Page 9 - pingback on September 19, 2012 at 3:13 am
  16. Paul –

    I have been eating low-carb paleo and IF 18/6 for the last 6 months and have been able to reduce some bodyfat which was the goal. I would like to continue, so I added keto to the mix in the last couple weeks, increasing fat to about 65%, protein @ 30%, and carbs 5%.

    2 weeks prior to starting keto, my latest CMP showed elevated BUN (36 – ref range: 6-24), elevated BUN/Creatinine ratio (39 – ref range:9-20), and elevated urinary uric acid (1118.0 – ref range: 250.0-750.0). I also showed elevated serum calcium (10.9 – ref range: 8.7-10.2). My serum uric acid (UA), however, was normal (4.6 – ref range: 3.7-8.6) as is my creatinine (0.92 – ref range 0.76-1.27) and eGFR (95 – ref range >59). There is no protein in my urine. I do not have gout. These levels have gradually increased over the last 6 mos. after being on the above diet.

    Just yesterday noticed blood pressure remained elevated all day despite my usual BP-lowering supps. First time ever they had zero effect. I wonder if the increased intake of fats (SFAs) on the keto/low carb diet are causing this, as I have changed nothing else perhaps by increasing total cholesterol?
    http://www.ncbi.nlm.nih.gov/pubmed/9021429
    but this contradicts that:
    http://weightoftheevidence.blogspot.com/2006/02/what-does-saturated-fat-do-to-your.html

    Or could this all be the beginning stages of kidney dysfunction, as it goes hand-in-hand with hypertension? Or – perhaps these are just transient.

    According to this article, keto may help reduce BP, but may cause kidney stones as you’ve pointed out, the very thing I’m trying to prevent from recurring (I passed one in March, my first).

    Perhaps I should cycle my protein intake as well as carbs? Increase fat even more?
    And what amount of water is recommended for low-carbers? Gallon/day?

    There are two types of keto diets, CKD (cyclical) and TKD (targeted). TKD is one where you will eat carbs (<50g) right before and right after your workouts. CKD is one where you will eat a minimum amount of carbohydrates per day and then carb up on the weekend (or at a time that is appropriate for you).

    What do you recommend?

    I'm at a loss as to what else I can do.

    • Hi Mark,

      Well, first, I guess I’d ask why you want to eat a ketogenic diet. It’s not necessary for weight loss. A 30% carb diet will do great for weight loss and won’t have this problem.

      The problem is likely to be due to oxidative stress. It’s possible (a) you’re eating an excess of fat or (b) you’re deficient in key antioxidants like copper, zinc, or selenium. You might want to check out our recommended supplements (updated since the book).

  17. Paul – Strict fat loss is why I’m on keto/IF/paleo. At 19% bodyfat, there’s no way I can increase carbs to 30% of my diet which would put me @ about 150g carbs/day which will cause fat gain. Total weight & weight loss is meaningless. It’s all about body composition (fat-free mass to fat ratio). If I was at my goal of 10% bodyfat, then maybe going a little higher on carbs. I take a ton of supps including he ones you mention. I also take T3 for hypothryoidism whch I realize can worsen on low-carb. It’s all suck a delicate balance and so difficult to sort out.

    • Why do you think 30% carbs would cause fat gain? Have you done the experiment?

      • Paul – I was doing 100g+ carbs easy daily before switching to <=75g and now, even lower. The result: higher bodyfat. Besides the 300 extra calories, I just don't need that much food converting to glucose/insulin.

        • Mark at 19% BF without other confounders you should be able to lose without resorting to such aggressive tactics. I think Paul’s overall weight-loss suggestions — http://perfecthealthdiet.com/2011/02/perfect-health-diet-weight-loss-version/ — ring pretty true. Basically:

          * eat the PHD — even the carbs
          * supplement for micronutrient balance (you have this)
          * reduce calories a bit from fat

          I would add to this:

          * don’t try and lose too fast (i.e., don’t literally run your ass off — skip most cardio, especially steady state medium intensity — and don’t cut calories more than 15-20% of your daily expenditure)
          * weight train to maintain muscle, but only 1-2x/week depending on intensity
          * consider having a one-day-per-week calorie spike post-lifting to encourage muscle growth/anabolism
          * expect stalls and plateaus but stressing about them will probably hurt your cause.

          My n=1 (after 25y of every other attempt under the sun, keto and all) tells me there’s no way around calorie restriction; you have to be patient about it; and, at a certain point, there’s probably no way to get the body of a teenager… unless you’re pretty recently out of your teens.

          • John – I have been doing IF/paleo for the last 9 mos., so I’m definitely not fast-tracking my fat loss. Again, everyone has it wrong. Weight loss means nothing as much as having the correct body comp (I can weigh more than now, but have more muscle and less bodyfat which is the key to better health and metabolism), so I have no interest in “losing weight” per se. My goal is targeted FAT LOSS which is different. In cases in which bodyfat is proportionately higher than one’s fat-free mass, then yes, total weight will drop accordingly. Besides IF, a CKD or TKD keto diet is the only other effective way I know of to specifically drop bodyfat without losing muscle mass. In most conventional weight loss situations, you lose a proportionate amount of muscle as fat and wind up looking skinny fat which is totally unhealthy.

            If you did keto, then you know it requires one to increase fat to 65-70%, protein low-moderate @ 25-30%, carbs @ 5% which. at first glance and without looking at the science appears absurd and downright unhealthy. That was my reaction until recent.

            Many have reported success with keto. I am only just starting (2 weeks). I really would like to try it and see if I can drop anymore bf. If 50+ yr old natural bodybuilders can maintain 10% or less year-round, so can I. Of course, some are chemically-enhanced, but I believe in sensible HRT with it especially making sense at my age (52), not AAS abuse. HRT is next on the list. While the diet and training will only go so far, sensible HRT will get you as close to teenage levels no doubt.

            I see that Paul’s approach emphasizes more carbs than fat which is just the opposite of what I am gleaning right now. At this point, like I said, I’ve tried higher carbs (30%) and lower fats before and that did nothing to reduce bf, so who knows until I give keto a fair trial. Everyone’s different. All I know is that I need to become an efficient FAT BURNER not an efficient SUGAR (carb) BURNER. And for now, that’s why something like keto makes sense. Also, in my case, it is NOT a zero carb diet. With TKD, you carb up bigtime on the weekends and on CKD, you have carbs, but only pre or post workout.

            My alarmist concerns posted earlier today were spawned from seeing my BP shoot up which I’ve been told by the keto “experts” is a transient rise from the transition from moderate to low carbs and higher fats. We’ll see. I still have no idea what it could be.

            Also, IF is already a form of CR, and the science says a better version of it.

          • Can’t reply to you directly Mark (too many replies), but OK. Paul’s post says “weight loss” but my comments were all regarding body recomposition, which I think was clear.

            If you want weight loss, I find amputation to be the most effective.

            Anyway, good luck.

          • Sorry, Paul, as you have witnessed being succinct isn’t one of my strong points! Just wanted to clarify.

            Yes, amputation is a surefire method for weight loss 😆

  18. Paul – How could you tell how much sodium you needed as indicated in your article? Also, how much water/day?

  19. In defense of fat, I found this excerpt from Alan Gaby, M.D.:

    “The amount of fat in the diet appears to be much less important than the type of fat consumed and the overall quality of the diet. Fats that appear to be harmful include trans fats and heated polyunsaturated fatty acids (as in cooking at high temperatures with sunflower, safflower, soy, corn, or canola oil).

    The relationship between saturated fat and heart disease is complicated and controversial. Saturated fat per se does not seem to be particularly harmful, as suggested by the observation that Polynesian people eat large amounts of saturated fat (mainly from coconut oil), but have a low incidence of heart disease. However, certain foods that are high in saturated fat may promote the development of heart disease for reasons unrelated to their saturated fat content. For example, advanced glycation end products and cholesterol oxides (both of which promote the development of atherosclerosis) are formed during cooking and processing of foods such as beef and dairy products. As is likely the case with dietary cholesterol, the effect of saturated fat-containing foods on heart disease risk may depend as much or more on how the foods are prepared as on the amount of saturated fat they contain.”

  20. Hey Paul,

    I’ve been messing around with my diet for a while, I recently did a VLC diet for a few months and felt amazing (after I address some mineral imbalances), then I found my way here and decided to increase my carb intake a bit.

    I now feel ok, but am really missing the kind of euphoria that ketosis seemed to bring. My main reason for upping my carbs was to try and address the dehydration issues I seem to keep having (I wake up with dried lips and really need a drink) and have basically been dealing with it by having a few pinches of himalayan salt with a glass of water or two every morning when I wake up, and taking a magnesium supplement every day.

    I was just wondering if you had any idea what else may be causing these problems, as it seems to be unrelated to ketosis (since I am no longer eating VLC).

  21. Paul,

    Jimmy Moore just posted his urine test results:

    http://livinlavidalowcarb.com/blog/jimmy-moores-n1-experiments-nutritional-ketosis-day-211-240/17390#comments

    I am little bit concerned with his 3+ protein, rbc in urine, calcium oxalate crystal, cloudy and foamy urine, all indicating some sort of kidney damage. You know Jimmy is doing low carb for years, is this caused by lower intake of carbs, or higher intake of protein ?

    Kang

    • Hi Kang,

      Probably too low in carbs. Higher protein might be protective, but I don’t know exactly what he’s eating.

      In addition to the urine issues you mention, his LDL is over 300 and TC over 400. The “high LDL on low carb Paleo” problem that we’ve blogged about.

      • Paul,

        My LDL used to be over 300 when I started low carb (3 month into low carb), it sits just below 200 right now, just by eliminating eggs and cheese. I believe the elevated LDL on low carb is primarily caused by the higher intake of cholesterol from food. If I go veg (which I won’t), I could probably reduce it even further.

        Kang

        • Hi Kang,

          Higher intake of cholesterol from food wouldn’t matter if cells were taking up cholesterol from the blood. It’s the lowering of uptake which is the dominant factor. You should be able to eat unlimited cholesterol and still maintain stable serum lipids.

          I would consider adding carbs, protein, or choline in such cases.

          • Thanks Paul.

            The problem is I have limited capacity to add carbs because of T2, and I am already eating a lot of meat which means enough protein and choline ?

            I am not overweight or underweight or anything like that, what else might help ? I am eating 50g to 80g of carbs now, and that’s the maximum I can tolerate. No medicines, no crazy exercise.

            Kang

          • Hi Kang,

            Try supplementing choline, or eating more liver and egg yolks. A little vitamin B6 and biotin might help also.

            Cholesterol in food is usually only a problem if there aren’t enough phospholipids to package them with.

          • Ok, I’ll try supplement choline, will let you know how it goes.

  22. I would look at two things that might adjust LDL; is your fish intake optimal, and are there types of fibre foods that would help occasionally by binding cholesterol as your gall bladder excretes it. Pectin is highly rated, and I like mucilaginous fibre like flaxseed. Once or twice a week seems to be enough.
    Also consider whether probiotics (if you dn’t already use these) would lower LDL.
    http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8560293

    • Thanks George.

      Fish, fish oil, flax seed, wheat bran and psyllium husk, I have tried them all, but don’t know whether it is optimal. Limited success.

      May be I should try probiotics (after the choline).

  23. Hello mr.jaminet,

    thanks for your blog! it’s only to point that i recently read on a book that defends Dukan’s diet wrote by a MD that happens to have only one kidney since he was a child, and he links the occurence of kidney stones in those children of the early ketogenic studies to the prevailing idea of water in those days, ie, that water should be consumed in small amounts because it was thougth to provoque interferences with ketonic bodies production, and that was though to lessen their positive effects

    regards

  24. Hi Paul,

    Reading this the 3rd time I just picked up something I have missed, the omega 3 issue. As someone who is prone to kidney stones, I am currently taking 1000 mg DHA/250mg EPA daily, and I just stopped VIt. C supplementation, so can I assume that I should cut out the fish oil capsules and just eat fish, or avoid both all together? I will work to up my antioxidant status with glutathione, zinc, and ALA. Lastly, I assume that the perfect health version of keto is out for me? Thanks as always for your key contribution to public health!

  25. I suspect that much of this problem, a rare one, is the fact that low carbohydrate dieters are not eating diverse organ meats, possibly avoiding fats. The hunters and gatherer, upon whose dietary habits vic diets are inspired by, were often particular about the type of animal, its organs and state that was eaten. Wild game is also likely to be dense in minerals such as the aforementioned selenium.

  26. Hi Paul,
    As always I enjoy reading your informative articles.
    I am very confused about the Vit C, oxalate connection.
    These 3 papers seem to suggest Vit C can cause damage in some people:
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472830/
    http://www.hindawi.com/journals/ijn/2011/146927/
    http://www.nature.com/ki/journal/v63/n3/full/4493529a.html

    I am now worried that I am one of those sensitive to oxalates. Since starting PHD I have been having about 1g Vit C daily and more spinach than I’ve ever eaten in my life (usually 2 or 3 times per week now).
    I am worried that it is causing oxaltes irritating my bladder area. I seem to have developed symptoms of cystitis. My bladder feels irritated when full and some pain in the nearby area.
    I am now concerned.
    Is there anyway I can check if it is to do with oxalates in my case?

    I currently have a castor oil pack on my lower abdomen which is providing relief. I don’t know what else to do. Perhaps I should cut out high oxalate foods for a while and see if it makes a difference?

  27. Do Low-Carb Diets Cause Kidney Stones - pingback on April 30, 2015 at 12:20 am
  28. Kidney Problems From Low Carb Diet | Kidney infection treatment - pingback on April 24, 2016 at 3:26 pm
  29. Hi Paul,

    I live in Australia. I bought your book and am doing the Ketogenic diet due to migraine – curtailing eating until 11am (whilst eating coconut oil – approx 2 tablespoons ) and eating gluten free grains and starchy vegetables for carbs. I also am heavy handed with coconut oil when I cook.

    I recently had back pain around the kidneys so ended up having an ultrasound. It showed an abnormality on one kidney but they called it an “acceptable variation” due to the kidney being fine. Anyway I also had some blood and urine tests. My bloodwork showed borderline iron – 32 – (despite eating meat, vitamin C etc) – actually my iron is always around the borderline. All else was fine bar my urine creatinine. It was 4.4 (the doctor said it should be below 2).

    I wanted to see what you thought that would cause this and what I can do to get it under control – I have read chamomile, cinnamon and stinging nettle are supposed to help. The doctor has also said she could write a referral to a kidney specialist if I wanted it.

    Thanks.

    Michelle

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