Thrive on the Keto Diet By Avoiding These (Common) Nutrient Deficiencies

By Bogdan Popa, M.D.

KEY POINTS

• Being overweight is highly correlated with having a nutritional deficiency (80.8% of the time).

• Keto, Atkins, DASH, and other restrictive diets can make deficiencies worse as opposed to better.

• Folate (B9), biotin (B7), selenium, choline, vitamins A, E, D, chromium, iodine, magnesium, and molybdenum are among the most common deficiencies that can develop while on a restricted diet like the ketogenic (or “keto”).

• Strategizing the types of foods you include in your diet and the supplements you take while on keto can reduce and/or correct the underlying issue, allowing you to lose weight while maintaining micronutrient balance. Top “keto” foods to eat to prevent deficiencies are: grass-fed, pastured meat, poultry, wild caught fish, liver (and cod liver oil), spinach, kale (green leafy vegetables), nuts, and seeds.

STARTING A DIET

We all go on a diet once in a while with the goal of losing weight that we might have gained over a holiday or during a difficult time. Sometimes we just want to slim down a bit.

What may surprise you is that chronic vitamin and micronutrient deficiencies (in other words, not getting enough vitamins, minerals, and antioxidants for optimal health) might just be the reason we’re carrying that extra weight. At least one study has shown a correlation between nutrient deficiencies and obesity. There was an “80.8% increased likelihood of being overweight or obese in micronutrient deficient subjects.”(1)

We tell ourselves we’ll go on a diet and shed those extra pounds and then we’ll be healthy. But it doesn’t necessarily work that way. Nutritional deficiencies don’t go away unless the new “diet” contains a wide array of nutrient-dense foods, like colorful raw vegetables and organic grass-fed meat, pastured poultry, and wild-caught fish. But the most popular diets, such as keto, often restrict an entire class of macronutrients (also known as macros), referring to carbs, fat, and protein. This can inadvertently eliminate foods that are rich in nutrients.

Keto, Atkins (both considered low-carb), and the DASH diet (considered low-fat) are a few examples of restricted diets. When we go on one of these restricted diets we can become even more deficient in certain vitamins and nutrients.

A study comparing four of today’s most popular diets—Atkins (the original ketogenic low-carb diet and a close relative of the keto diet), DASH, Mediterranean, and South Beach—showed none were able to meet the minimum RDI (daily intake level considered sufficient) for the 27 essential nutrients normally included in all multivitamins and considered “essential.”(2) In addition, 6 of the 27 key vitamins and nutrients studied were found to be extremely low or nonexistent in the diets studied (see below). Micronutrients (such as B vitamins), minerals (like selenium, magnesium and iodine), and antioxidants (including vitamin A and E) regulate our metabolism, moods, cravings, hormones, and energy levels.

Can diets such as keto actually contribute to cravings and the nutrient deficiencies that are making us fat in the first place? More importantly, is there a way to not only avoid these deficiencies, but to replace and correct them? How can we feel better (and healthier) when we’re shedding pounds when dieting? 

Let’s take a closer look at what the evidence shows us and how we can hack our way to nutrient and weight-loss success simultaneously. 

The KETO DIET

Unlike its predecessor, the Atkins diet, the Ketogenic (or Keto) diet not only restricts carbohydrates, but also protein. This aims to induce a state of fat breakdown into fatty acids, which become the fuel that cells use for energy instead of glucose. As many of you readers already know, the keto diet has shown a lot of promise and has the following benefits:

1. Weight loss

2. Anti-seizure activity

3. Correction of metabolic syndrome

4. Prevention of onset and decreased progression in Parkinson’s and Alzheimer’s disease

5. Protecting against Cardiomyopathy (heart muscle disease)

6. Potentially adjunctive therapy for cancer

But even with these benefits, potential nutrient deficiencies have been shown to occur with keto and other restricted diets, especially when these diets are prolonged. The good news is we can devise a way to make sure you don’t encounter them while attempting what can be an effective lifestyle diet. 

Let’s take a closer look at specific vitamin deficiencies that can happen when dieting:

Folate (Vitamin B9)

Folate is necessary for life to occur. Yes, it is that critical to our existence. Every minute every cell in our bodies depends on folate.

Among its many functions, B9 acts as the centerpiece of a process called “methylation,” which keeps all of our cells functioning, and without which, they would die. Methylation is responsible for pretty much all of our second-by-second functioning: energy production, hormone balance (estrogen synthesis and breakdown), gene expression, mood control, and cravings.

Try to fight those carbohydrate-eating impulses without enough folate and you will likely fail. Folate regulates neurotransmitters (like serotonin and dopamine) that control our urges and are responsible for our sense of contentment and happiness. Folate is also used up to make the DNA for rapidly dividing cells (found in the skin, lungs and lining of the gut) and to make red blood cells. Undoubtedly, you can now see why it’s important to have plenty of B9 around, but, unfortunately, folate levels can run low in keto and Atkins-type diets.

In a 2018 retrospective study of over 11,000 pregnant women who delivered over a 13- year period, it was concluded that mothers who were on a restricted carbohydrate diet were 30% more likely to have a fetus with a neural tube defect (spina bifida and anencephaly). The reason concluded was that the “mean dietary intake of folic acid among women with restricted carbohydrate intake was less than half that of other women.”(2

Since the keto diet restricts carbohydrates to an absolute minimum and many plants have carbohydrates, it is easy to see how avoidance of leafy greens, for the purpose of avoiding carbohydrates and maintaining ketosis, can result in a gradual depletion of a source of folate (B9). 

Folic acid, a precursor to folate, is well known and religiously taken by childbearing women as a supplement before and during pregnancy. However, folic acid is not present in nature, and it isn’t advisable to take folic acid as a supplement (whether you are pregnant or not). This is because folic acid needs to go through a complicated process to become usable by our cells in the form of “active” folate, or “methyl-folate."

The main enzyme that carries out this conversion of folic acid to “active” methyl-folate is called Methylene Tetra Hydro Folate Reductase (MTHFR). 10-50% of us have mutations called SNPs (genetic variations called “snips”) that slows MTHR from 30-80%, making it difficult to maintain normal folate levels, even before being on a restrictive folate diet, such as keto. 

It’s easy to find out if you have any of the several types of the MTHFR mutation as testing is becoming more mainstream (see below). If you test positive for the mutation, it is much better to take methylfolate as a supplement instead of folic acid.

So, getting enough folate while on the ketogenic diet is essential for your long-term health as well as success.

Action Items:

• If you’re on a no-carbohydrate or extremely low-carbohydrate diet, make sure you eat 1-2 portions of leafy green vegetables, such as kale, chard, and spinach, every day.

• Ask your doctor to test you and if you have the MTHFR mutation. Quest and LabCorp, the two main laboratories nationwide, have these tests readily available and they are becoming more mainstream. If you’ve done a 23andMe genetic test, you may already have this information (along with hundreds of other genes) available in your account as a .txt data file you can download. Once you have this file, you can upload into an interpretation software like StrateGene (no affiliation). Note: This report is quite extensive and detailed and may require interpretation help from a doctor.

• If you have an MTHFR mutation, you will need to be careful as the depletion in folate with the keto diet could drain your energy, and potentially cause mood swings and out-of-control cravings due to folate’s role in having enough dopamine and serotonin, our “cravings'” specific neurotransmitters.

• If you want to ensure you have enough folate while eliminating most carbs, consider taking an “active” folate supplement—a methylated form of folate that is ready to use by the body. Adding active B-12 (methylcobalamin) usually makes methylation work even better, especially if you carry mutations such as MTRR, which affect your ability to make “active” B-12. Testing is easy and this is also available in your 23andMe report.

• Avoid “folic acid” supplementation as folic acid as it needs to be converted to the active methylated folate form and this process can be significantly slowed, especially when dealing with the MTHFR or MTRR mutations (mentioned above). If you have an MTHFR mutation, folic acid can actually be detrimental as it accumulates and will compete with folate for its receptor, preventing it from doing its work.

Low Vitamin B7 (Biotin), Vitamin A, Vitamin D, Vitamin E, Chromium, Iodine, Selenium, Magnesium, and Molybdenum

Six micronutrients (vitamin B7, vitamin D, vitamin E, chromium, iodine, and molybdenum) were identified as consistently low or nonexistent in all four diet plans in the study mentioned above(2) which compared the Atkins, South Beach, DASH, and Mediterranean diets. Keto restricts carbohydrates and protein even more than Atkins. Furthermore, all 27 essential nutrients typically present in a multivitamin were way below 100% RDI in all four diets.

The study concluded that one would have to eat 3,475 ± 543.81 calories to cover 100% of the RDI in all four of the diets studied. This would obviously defeat the purpose of dieting.

Here are the 27 essential micronutrients used in the study and suggested keto-friendly food sources are listed below:

NUTRIENT

KETO-FRIENDLY SOURCE

Vitamin A

Cod liver oil, orange vegetables

Vitamin B1 (thiamine)

Beef, liver, nuts

Vitamin B2 (riboflavin)

Nuts, lean meats, poultry, eggs

Vitamin B3 (niacin)

Turkey, tuna, salmon, liver, avocado

Vitamin B5 (pantothenic acid)

Beef, poultry, fish, broccoli, avocado

Vitamin B6

Pork, fish, eggs

Vitamin B7 (biotin)

Liver, egg yolks, nuts, seeds, avocado

Vitamin B9 (folate)

Spinach, Brussels sprouts, kale, liver

Vitamin B12

Beef, liver, chicken, fish, eggs

Vitamin C

Broccoli, Brussels sprouts, lemons

Vitamin D

Salmon, cod liver oil, sardines, eggs

Vitamin E

Vegetable oils, almonds, spinach

Vitamin K

Kale, chard, spinach, cauliflower

Choline

Eggs, liver, meat, poultry, fish

Ca (calcium)

Chia and other seeds, sardines, almonds

Cr (chromium)

Broccoli, green beans, meat

Cu (copper)

Liver, organ meat, oysters, nuts, seeds

Fe (iron)

Shellfish, spinach, liver, organ meat

I (iodine)

Seafood, seaweed, iodized salt, eggs

K (potassium)

Spinach, leafy greens, sweet potatoes*

Mg (magnesium)

Spinach, almonds, dark chocolate*

Mn (manganese)

Nuts, leafy vegetables, teas

Mo (molybdenum)

Almonds, cashews, eggs, leafy greens

Na (sodium)

Sea Salt or Himalayan, shellfish

P (phosphorus)

Chicken, turkey, pork, seafood, seeds

Se (selenium)

Brazil nuts, seeds, mushrooms, seeds

Zn (zinc)

Meat, shellfish, eggs, nuts, seeds

Choline (RDI not established)

Eggs, liver, meat, shellfish, spinach

*Chromium (*not considered essential nutrient)

Broccoli, beef, poultry, green beans

Biotin

Also known as vitamin B7, biotin deficiency is usually associated with symptoms such as thinning hair, dry skin, scaly rashes, brittle nails, conjunctivitis, depression, fatigue, numbness and tingling in the arms and legs. Biotin is naturally found in keto-friendly foods such as liver, egg yolks, meat, salmon, avocados, and cauliflower.

However biotin is used up extensively in the processing of fatty acids while on the keto diet. In an animal study, biotin deficiency developed at 7 weeks in mice fed a strict ketogenic diet. The typical manifestation of biotin deficiency, including hair loss and dermatitis (inflammation of the skin, rashes), developed.

For this reason, it is suggested by the authors of this study that individuals embarking on a ketogenic diet consider supplementation with vitamin B7.(3)

Selenium

A versatile and critical trace mineral, selenium plays many roles in the body. It acts as an antioxidant neutralizing damaging free radicals. It boosts immunity, ensures normal thyroid function, stimulates blood flow and protects against heart disease among its many other benefits. Selenium is found in the following keto-friendly foods: Brazil nuts, mushrooms, oysters, tuna, liver, and meat.

Even though it is abundant in these foods, selenium deficiency is actually a well-known complication of a long-term ketogenic diet.

A study of 110 children with epilepsy who were maintained on the ketogenic diet for more than 12 months were shown to have decreased levels of selenium.(4)

Although the consequences are not usually severe, selenium deficiency can rarely become life-threatening. This was the case in a 5-year-old who had a normal selenium level before starting a ketogenic diet, but then developed cardiomyopathy (heart disease) and ventricular tachycardia, a fast and potentially life-threatening heart rhythm. It was suspected and confirmed by blood test that his selenium levels were severely deficient and his condition fortunately completely normalized and reversed after receiving immediate selenium supplementation.(5)

Choline and Non-Alcoholic Fatty Liver Disease (NAFLD)

Over 3 million Americans suffer from fatty liver disease (NAFLD). The good news is that the keto diet is actually helpful short-term in treating fatty liver.

The bad news is that, taken to extremes of very high fat intake at the expense of carbohydrates and protein, fatty liver could potentially worsen, unless we provide enough choline and methionine in our diets.

Although the same effects have not yet been verified in humans, a study in mice showed that extreme restriction of both carbohydrates and protein should be avoided because of potential development of fatty liver Non-alcoholic-Fatty Liver-Disease (NAFLD) or even worse, progression of the fatty liver to actual liver damage as is seen in Non-alcoholic Steatohepatitis (NASH).

Fatty Liver NAFLD, Fatty Liver cellular damage (inflammation), as in NASH, and insulin resistance, as in pre-diabetes, developed in the animals in this study when they were maintained on a very high-fat (93.3%), very low-protein (4.7%), and extremely low-carbohydrate levels (1.8%).(6)

While most of us would avoid eating 93.3% fat in our diets, this study stands to warn us of becoming too obsessed with restricting carbohydrates and protein, especially when done simultaneously. When these extremes are employed, the body becomes depleted of an essential nutrient called choline, a nutrient highly concentrated in egg yolks, but also available in liver, meat, poultry, and fish. Similarly, it is suspected that the very low-protein content and low availability of the amino acid methionine may also be a direct contributor to the development of fatty liver.

Choline deficiency is well known to cause fatty liver all by itself. Fortunately, when choline was added back to the diets of the mice (in the above mentioned study) maintained on 93.3%-fat diets, the fatty liver effect was reversed.

It stands to reason that maintaining healthy choline and methionine levels in our diets or through supplementation is essential in avoiding fatty liver and potential liver damage when we go through a prolonged and extreme keto diet phase. Choline is and essential nutrient involved in normal metabolism and transport of fats, neurotransmitters, homocysteine, and heart health. Choline present in such keto friendly foods as eggs, liver, meat, poultry, and fish. Methionine is an essential amino acid important in making cartilage, stronger hair and nails. It is present in suck keto-friendly foods as nuts, meat, lamb, poultry, fish, and eggs.

Action Items:

 • Eat a varied diet, including organic grass-fed meat, pastured chicken and pork, wild-caught fish, eggs, bone broth colorful raw vegetables and leafy greens in order to get the full spectrum of B vitamins and minerals needed to maintain energy and metabolism levels normal and avoid nutrient deficiencies.

• If your diet is very restricted and does not include a wide spectrum of foods (as mentioned above) or if you want to be absolutely sure to cover all bases, choose a multivitamin that contains all the micronutrients mentioned in this article. 

• Pick a multivitamin that is highly absorbed. There are many great choices out there but we recommend our Liposomal B-Complex with minerals and antioxidants. You will get all eight of the B-vitamins in their “active” forms, such as methylfolate (active B9), methylcobalamin (active B12), P5P (active B6), biotin (B7), a full spectrum of antioxidants (vitamins A, C, E), as well as all of the trace minerals including selenium, molybdenum, manganese, chromium, and iodine. If you’ve never heard the term, “liposomal,” it means that the active ingredients are delivered within liposomes, microscopic spheres made, in this case, of naturally occurring phospholipids (the building blocks of cell membranes) extracted from non-GMO sunflower. The main phospholipid present in the liposomes, Phosphatidyl-choline, will provide a rich source of choline, as well.

CONCLUSION

Embarking on a diet such as keto can be hard, but knowing about nutrient deficiencies that can develop and how to conquer them can help set you on the fast track to success, lower cravings, and increased energy. Pay particular attention to include varied foods in your eating plan that are packed with micronutrients, such as folate, biotin, selenium, and choline, and consider supplementing with a highly absorbed multivitamin containing “active” B vitamins.


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