Photograph by Bobby Doherty / New York Magazine
The Plant-Based Ketogenic Diet
A lot of diets come and go, but for the most part, we live by the idea that if there aren’t vegetables at the heart of one, it can’t be that great. Which is why we find Pittsburgh-based functional medicine practitioner Will Cole, IFMCP, DC’s plant-based approach to a high-fat, ketogenic diet so compelling.
The gist is to eat a variety of vegetables and lean on healthy fats instead of carbs for energy. It’s a strategy Cole has found works well for most of his patients. It’s also a lot less restrictive than the standard ketogenic approach. In Cole’s practical food book, Ketotarian, there’s significantly more space devoted to all the things you could eat than the things you shouldn’t. And the message is really: Don’t sweat the small stuff, but once you get the ball rolling, you’ll actually…enjoy it.
A Q&A with Dr. Will Cole, IFMCP, DC
Ketotarian is my plant-based keto approach. Whether you’re making your own meal or eating out, these are the basic guidelines to follow:
Eat real food.
Keep your carbs low.
Keep your healthy fats high.
If you eat a nonstarchy vegetable, add some healthy fats.
If you eat a healthy fat, add some nonstarchy vegetables.
Eat when you are hungry.
Eat until you are satiated.
Just because something is “low-carb” and “high-fat” or “keto” doesn’t mean you should be eating it. The conventional keto diet often focuses too heavily on dairy, meat, and artificial sweeteners, all in the name of being low-carb and high-fat. This can sometimes work for people to lose weight and gain energy in the short term but has potential long-term health impacts that concern me. Our gut microbiome needs a variety of plant foods for rich bacterial diversity to thrive. With conventional keto, people may focus too much on saturated fats, and I often see inflammation levels spike on labs for people with gut problems and gene mutations (such as the APOE4 allele). Plus, some people have difficulty digesting a lot of dairy and meat.
A ketogenic diet puts your metabolism in nutritional ketosis, a fat-burning state that eschews the volatility of swinging between high and low blood sugar and has the effect of curbing most cravings. There is so much exciting research emerging on ketosis and the main ketone your liver produces, beta hydroxybutyrate (BHB). When you get your body to produce ketones—which is what follows naturally when your body burns through all available carbs—they can also pass through the blood-brain barrier, providing your brain with clean, efficient energy.
Our brains are made up of 60 percent fat and require a lot of energy production to work optimally. From both an evolutionary and a biological perspective, the most sustainable form of energy for your brain and body is healthy fats—not sugar. The ketone BHB has been shown to preserve brain energy levels, protect against neuron death, and lower brain inflammation. Ketones are also thought to be epigenetic modulators, which means they could beneficially regulate gene expression related to metabolism and longevity. Most of my patients are somewhere on the autoimmune-inflammation spectrum, so one of my favorite lifestyle applications of ketones is that BHB is a strong anti-inflammatory1
Ketotarian is meant to be a healthy lifestyle for anyone looking to explore the health benefits of ketosis. I suggest going plant-based keto for at least eight weeks to give your body time to shift from sugar-burning to fat-burning.
After sixty days, reassess where you are and how you feel. If you like where you are, you don’t need to change anything. You’re eating some of the most nutrient-dense foods on the planet. But does everyone need to stay in nutritional ketosis permanently? Absolutely not. You’ll find your groove. You’ll experiment with plant-based keto meals; maybe test out other ketogenic tools, like intermittent fasting; and find your personal carb tolerance. After those two months, I typically suggest spending varying times out of ketosis by increasing your healthy carbs and paying close attention to how you feel.
What makes ketotarianism so sustainable is that it is centered around balance and finding what works for you. Have fun with it. Everyone’s different; many people who are prone to insulin or weight-loss resistance, insatiable cravings, or neurological problems thrive staying in longer-term nutritional ketosis. Others do great with moderating their carbs seasonally or even throughout the week, eating plant-based keto around four to five days a week and increasing their carbs the other two to three days. Some people do just fine with more carbs from real food but love to go back into ketosis when they want a reset.
Since vegetables contain varying amounts of carbs, many well-intentioned people who go keto end up limiting or avoiding vegetables long-term. Let me explain why this fear of vegetables is unwarranted:
Total carbohydrates are all carbs found in your food. Net carbohydrates, on the other hand, are total carbohydrates minus the fiber and sugar alcohols that your body does not digest. Carbs from real foods, like vegetables and avocados, contain both insoluble and soluble fiber. Insoluble fiber in particular (such as cellulose and lignin) can’t be absorbed by the body, so it has no effect on blood sugar and will not take you out of ketosis. Soluble fiber is useful, too. It’s fermented by microbes in your gut microbiome, where it is transformed into beneficial short-chain fatty acids (SCFAs): acetate, propionate, and butyrate. The concern in the mainstream ketogenic world is that soluble fiber can increase blood sugar levels, thereby negatively impacting ketosis. However, studies have shown that soluble fiber can actually lower blood sugar levels.
The SCFA propionate is used by the body for intestinal gluconeogenesis (IGN), making glucose in the intestines. Through the IGN pathway, SCFAs actually bring about a net decrease in blood sugar. So unlike liver gluconeogenesis, which can throw someone out of ketosis by raising insulin and blood sugar levels, IGN seems to help balance blood sugar levels. Fiber also helps your brain know when your stomach is full, which helps curb overeating.
The Ketotarian plan focuses on nutrient-dense, real foods, like vegetables, nuts, and seeds, which all contain carbs that are buffered and harnessed by whole-food fiber. When you are eating nonstarchy vegetables, avocados, olives, healthy oils, low-fructose fruits, nuts, and seeds on the Ketotarian plan, count your net carbs, not total carbs. Shoot for fifty-five grams or less of net carbs a day from these foods. In the beginning, food logging can help you become more conscious of how your food is fueling you and track what helps you feel the best.
If you eat processed, boxed foods—even the supposedly healthy ones—or any foods other than a whole food, count total carbohydrates.
One way to keep total versus net carbs simple is to not count carbs from nonstarchy green vegetables and avocado at all, because they are so low in carbs and so high in fiber. Count only fruit and starchy vegetables, like sweet potatoes, in your total carb count.
Also know that as you nourish your body with plant-based keto foods and your body becomes more metabolically flexible, you can get away from tracking carbs. You will intuitively know what works for your body and what doesn’t.
We all have a different tolerance to carbs, fruit sugar included. Some people can tolerate several handfuls of fruit a day and still get all the benefits of ketosis, while others who are more carb-sensitive will have to limit their fruit intake as their body becomes fat-adapted. In general, for the first eight weeks of becoming a fat-burner, I suggested limiting fruit to a maximum of two handfuls a day and focusing on low-fructose fruits, such as berries and grapefruit.
There are three ways to measure your body’s ketone levels:
Blood: the current gold standard. Similar to a blood sugar meter, it’s a simple home test.
Breath: exciting new technology that involves breathing into a meter. I prefer this one.
Urine: This is fine as you are starting out but not as accurate long-term.
If you are going plant-based keto just to try it, I don’t think most people need to test ketones once they get the hang of it and become fat-adapted. I want the Ketotarian plan to be an effortless, simple way of living—you can rely on natural clues that indicate your body is in ketosis:
You don’t get hangry anymore.
You have increased mental clarity and focus.
You have more sustained energy throughout the day.
You can go a few hours without wanting to eat or can skip meals easily (which is why intermittent fasting can be easy once you’re fat-adapted).
That said, people who use the ketogenic diet to manage health conditions may need to test ketones long-term, but that would be something to discuss with your doctor.
Two Ketotarian Recipes
Dr. Will Cole, IFMCP, DC, is a leading functional-medicine expert who consults people around the world via webcam and locally in Pittsburgh. He specializes in clinically investigating underlying factors of chronic disease and customizing health programs for thyroid issues, autoimmune conditions, hormonal dysfunctions, digestive disorders, and brain problems. His first book, Ketotarian: The (Mostly) Plant-Based Plan to Burn Fat, Boost Your Energy, Crush Your Cravings, and Calm Inflammation, is available here.
The views expressed in this article intend to highlight alternative studies. They are the views of the expert and do not necessarily represent the views of goop. This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice.