Whether the ketogenic diet is suitable or not for females has stirred up some controversy. Women are in a constant balancing act with nature; as far as biology is concerned, one of the primary functions of the female body lies in its ability to reproduce and to support another life. The female reproductive process is very energy-intensive and often makes women particularly sensitive to any sudden dietary or lifestyle changes.1 The ketogenic diet could potentially fall under either, or both, of these categories and therefore warrants some discussion.
If we take a look into our evolutionary past, humans did not always have access to the abundance of carbohydrates that surround us today, yet our species survived. We are here today, in part, because of ketosis. Ketones were the back-up fuel to get us through periods of food scarcity, ensuring our brain would receive adequate fuel without having to tear down our muscles in the search for glucose.2 Ketosis is a natural state for humans—regardless of gender—and one could argue that never experiencing ketosis over a lifetime is quite rare.3 The ketogenic diet is safe and effective, but some women may experience some challenges along the way.
A common concern regarding women and a ketogenic diet is that ketosis mimics the metabolic state of starvation. It is also crucial to understand that there is a difference between eating a diet to achieve nutritional ketosis versus eating too little and instead entering starvation ketosis.3 The solution is to recognize that context (and calories) matter.
Challenges women face on a ketogenic diet
Ketosis is known to suppress appetite and can lead to inadvertent calorie restriction. This could threaten the normal reproductive system. Calorie restriction may be problematic for some females during their developmental years, those who are at a healthy weight to begin with, or those who are pregnant or breastfeeding, or in female athletes.4-9 Unfortunately, the ketogenic diet often gets associated with the undesirable effects of chronic, and unhealthy, caloric restriction, despite this diet specifically cautioning against this.
Rapid and significant weight loss, and just being underweight in general, has been shown to cause irregular periods or even a complete cessation of menstruation.6 This is a telltale sign that your body has sensed something wrong and could be signaling that you are not eating enough. In regard to reproductive health, the rate of weight loss could be more detrimental than the total amount of weight reduction, further supporting the rationale for moderate, versus severe, calorie restriction.6
Pregnancy and breastfeeding
Pregnancy and breastfeeding require appropriate nutrition and caloric intake to support a healthy outcome. Normal pregnancy often results in a temporary state of insulin resistance, making pregnant and lactating women more susceptible to ketosis.7 Even just skipping breakfast has been shown to raise ketone levels threefold in pregnant women.8 If you are achieving ketosis during pregnancy or lactation, you run the risk of ketoacidosis or “runaway ketones,” which can be dangerous to the mother and for fetal development8. A small set of case reports have shown that ketoacidosis during pregnancy and breast feeding may be dangerous and result in serious adverse outcomes.7,10 Think of it this way: Glucose is essential, but too much is dangerous; the same applies for ketones. It is best to discuss any dietary changes, such as following a ketogenic diet, with your healthcare practitioner—especially during pregnancy and breastfeeding.
The cravings for chocolate, sweets, and carbohydrates around a woman’s time of the month are real.11 But who says you can’t feed those cravings on keto? There are delicious, keto-friendly versions of your favorite foods. Severely restricting the foods you enjoy often has the potential to lead to binge eating, so keep things real—just make it keto.12 Keep in mind that just because these foods are keto-friendly doesn’t give you free rein to consume them excessively.
When followed in a healthy, well-informed manner, ketogenic diet is an amazing and safe tool for women and men alike. The problems that could occur with a ketogenic diet in women appear to revolve around total energy intake, rather than the ketogenic diet or ketones themselves. Women are more vulnerable to changes in energy status due to some females’ goals to be prepared for reproduction. If you are an athlete, are young and still growing, and/or are underweight, the ketogenic diet needs to be properly administered and monitored to make sure you are optimally supporting your body’s various physiological functions. If you are pregnant and/or breastfeeding, the ketogenic diet and fasting may not be an appropriate option during those life stages. And finally, don’t deprive yourself of enjoying your favorite foods, just find low- or nonglycemic substitutes to keep it keto.
As always, don’t forget to discuss any dietary changes with your healthcare practitioner first!
- Vitzthum VJ. American Journal of Physical Anthropology. 2009;140:95-136.
- Cahill GF. Annu Rev Nutr. 2006;26:1-22.
- Cahill GF et al. Trans Am Clin Climatol Assoc. 2003;114:149-161.
- Martin B et al. Ageing Res Rev. 2008;7(3):209-224.
- Paediatr Child Health. 2004;9(7):487–503.
- Falsetti L et al. Gynecol Endocrinol. 1992;6:49-56.
- Scholte JBJ et al. The JCEM. 2012;97(9):3021–3024.
- Rudolf MC et al. Clin Endocrinol Metab. 1983;12:413-428.
- Warren MP et al. 2001;170:3-11.
- Alawi AMA et al. Case Reports; 2018:bcr-2017-223494.
- Krishnan S et al. Physiol Behav. 2016;165:304-312.
- Cohen IT et al. Hormones and Behavior. 1987;21:457-470.
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