DISCLOSURE: I’ve said this a few times before, but I’ll say it again.  While I don’t know him personally, I like Jimmy Moore.  He’s been a supporter of my site and has personally answered every single tweet and e-mail I’ve sent him.  He was also the inspiration behind my ketogenic n=1 experiments.  I pretty much just copied his n=1 nutritional ketosis experiment when I first read about it. If you’ve been following me at all you’ll know that I’m a big fan of ketogenic diets and have experimented with the different variations:

• strict ketogenic diet (Nutritional Ketosis)
• cyclic ketogenic diet (Carb Nite)
• targeted ketogenic diet (Carb Back-Loading)

After all of these experiments, I can say confidently that I’ve learned a lot more about everything ketogenic.  When I heard that Jimmy Moore was writing Keto Clarity I couldn’t wait to get my hands on it.  While I won’t go so far as to say that I’m an expert, I CAN say that I’m more than a novice, and I genuinely enjoyed this book and found it worthwhile read. The format of this book is similar to his prior book, Cholesterol Clarity, with blocks of text written by Jimmy interspersed with ‘Moments of Clarity,’ which are relevant quotes from the various experts that were consulted on this book.  I’m actually familiar with the work of many of these experts like Dominic D’Agostino, Nora Gedgaudas, Ben Greenfield, and of course John Kiefer.

While everyone’s portrait looks professional, Bill Lagakos’ picture stands out a bit (sorry Bill if you’re reading this).  I sort of imagine Jimmy asking him for a picture and Bill waiting until the last minute, discovering he didn’t have anything nice around, and just sending a random picture he had lying around, which Jimmy and his editors then had to crop out.

What I Liked

Jimmy’s plain spoken and friendly voice really comes across in the pages… almost as if you were listening to his podcasts.  You get the sense that everything he says is genuine and earnest without any hint of condescension.  It’s very easy to read, very easy to understand, and is something that anyone can appreciate whether or not they have a science background. This book definitely meets my ‘would I feel comfortable giving this to my parents’ criteria.  My parents have zero background in science but if they were ever interested in pursuing a ketogenic diet, this would be the first book I’d send them (right now they’re on a Perfect Health Diet kick). If you’re interested at all in learning about ketogenic diets, Keto Clarity is the first book you should definitely read. You’ll learn about Jimmy’s personal story, the history of the ketogenic diet, the basics of ketone biochemistry, all the potential health benefits, and the different ways to measure ketones. There are a few things that he emphasizes over and over throughout the book (enough so you grasp the importance, but not so much that it becomes tiresome):

• The three main pillars of a ketogenic diet: low carb, high fat, and moderate protein
• The difference between ketosis and ketoacidosis (only occurs in presence of high blood glucose and absence of ANY insulin production).

Since my memory is pretty crappy and I almost always forget what I just read (don’t even get me started on remembering names), I really appreciate the ‘Key Concepts’ he adds to the end of each chapter reviewing all the salient points he covered.  This format ensures that you will walk away with a good comprehension of what he writes about. He also provides plenty of anecdotes that further emphasize and support his points making things even easier to understand. There were so many things he talks about that I wish I knew about at the beginning of my own journey like:

• The fallacy of net carbs (something I had to figure out on my own).
• Why you shouldn’t test blood ketones immediately after exercise (again, something I had to figure out).
• The importance of finding your personal carb tolerance and protein tolerance levels AND how to do this

There are two chapters in particular that I think are worth the price of admission alone: the comprehensive “FAQ” and “Troubleshooting” chapters.  He addresses the most common challenges you will face and how to deal with them. He even goes into women’s issues.  Since I’m not female and the BJJ Cavewife isn’t interested in going ketogenic, I always skip over the ketosis + women issues when I listen to podcasts or read articles.  Luckily for us Jimmy does not.  If you’re wondering how it affects pregnancy, polycystic ovarian syndrome, periods, etc..  he covers it. To top it all off there are food lists, recipes, and meal plans.  He also provides a large bibliography listing all the studies that he references (the lack of resources was one of my biggest complaints of Cholesterol Clarity).

What I Didn’t Like

Protein and Satiety

He mentions multiple times that fat is super satiating and is the most satiating macronutrient.  He even says:

Consuming too much protein (and, therefore, getting more glucose in your bloodstream) can stoke hunger and cravings, and make you ravenous between meals.

It’s actually well established that protein is more satiating than fat.  You can find some examples of the research here, here, here, and here. Mark Sisson actually wrote a few posts addressing the satiating qualities of protein here, here, here, here, and here. I’ve even tried restricting protein myself while eating more fat and found that it left me STARVING. I agree that eating too much protein can kick you out of ketosis.  I also agree that fats are more satiating than carbs… but to say that protein can stoke hunger?!?!  That’s something I can’t agree with.

Ketosis and Hypothyroidism

There is a chapter dedicated to providing counter arguments to 10 common criticisms of ketogenic diets, and one of these criticisms is that ketosis causes hypothyroidism.  Jimmy’s main counterpoint is that it’s not the ketones and lack of carbs that causes hypothyroidism, but is instead the lack of calories. Experts like Dr. Ron Rosedale, Dr. Chris Decker, Dr. Jay Wortman, and Dr. William Davis all agree that ketosis can cause Free T3 (the active form of thyroid hormone) to decrease but specify that this actually indicates IMPROVED thyroid function and that this is a favorable and necessary adaptation to the physiological changes of a ketogenic diet….  basically they’re saying that the lower Free T3 that you get with ketosis is a GOOD THING because it means your thyroid doesn’t have to work as hard. Dr. William Davis specifically says:

This specific situation does not represent disturbed thyroid function, but rather a physiologic adaptation to limit weight loss by reducing metabolic rate, a survival mechanism that is meant to protect the body from starvation,” he explains. “These hormonal adjustments are transient and correct themselves over several weeks after weight has plateaued. But it does not represent thyroid dysfunction.

Now before I bring up why I have issues with this, there are two other quotes that I want to bring address. Firstly, a quote by John Kiefer written in this same section of the book:

We see a drop in thyroid hormone levels over the short term on a ketogenic diet, but that’s balanced by a more responsive sympathetic nervous system response.

While I don’t see anything wrong with this quote, I DO think it’s interesting that it’s used in the same section that is trying to disprove the relationship between ketosis and hypothyroidism.  Why?  Because Kiefer strongly believes in the importance of having at least one carb-up day (a la Carb Nite) for the exact purpose of preventing a down regulation in thyroid function and overall metabolism.  Kiefer never recommends a strict ketogenic diet for this reason and believe that you NEED the carbs and subsequent insulin response at least once a week for optimal health!  That’s why I think it’s odd that this quote was used as way to support this section. Secondly, in a section on the benefits of ketogenic diets on athletic performance, Jimmy writes an entire section on Ben Greenfield’s experience with running the Ironman Canada and Ironman Hawaii races whilst being in ketosis.  Jimmy writes:

Here are the major benefits Greenfield found from being in ketosis:

• Increased metabolic efficiency and enhanced fat burning, which lets him “get stronger as the day gets longer.” This is especially useful for endurance athletes, such as those participating in Ironman competitions and long-distance marathons.
• Sparing of glycogen stores, which also leads to increased endurance. He uses less stored muscle and liver carbohydrates because he’s able to burn fat more efficiently.
• Lowered inflammation, which enables his body to recover faster after a workout due to the decreased formation of free radicals and reactive oxygen species (molecules that can damage cells) from a high amount of sugar intake.
• More stable energy levels because his blood sugar levels don’t fluctuate as they would on a carbohydrate-based diet.

Doesn’t all this sound amazing?  Of course it does.  The only thing issue is that I know that Ben also reported quite a few problems with this and goes into specific details on these issues in podcasts with Dave Asprey and John Kiefer. I wrote a brief post about it here, but in short he experienced severe hypothyroidism with marked cold sensitivity, poor libido, and severe low energy.  He treated this by taking a lot of dessicated thyroid and eating lots of sweet breads and liver.  If I remember correctly he also reported a significant drop in his testosterone. The side effects were so bad that even though he completed the race and did relatively well, he concluded that trying to stay in ketosis all the time, despite the performance benefits, was just too difficult and inconvenient. Now this strikes me as a little bit of cherry picking on Jimmy’s part, I mean to selectively write about all the benefits without exploring any of the side effects doesn’t present the complete story.  Giving Jimmy the benefit of the doubt, he might not have been aware of Ben’s reported side effects so I can’t say for certain whether he cherry picked or not, but when I read this part, I definitely raised my eyebrows. If you want to know more about Ben’s experience you can check out this post where he goes over his initial plan, and then hear about his thoughts afterwards here and here (I think these last two require a paid subscription). Ok, enough about Kiefer and Ben Greenfield.  Jimmy also says this about ketosis and hypothyroidism in the book:

The problem with this criticism is that it is incomplete. While some on a ketogenic diet may experience hypothyroidism if they aren’t consuming enough calories, when calories are adequate, hypothyroidism doesn’t occur. It’s the number of calories, not the ketogenic diet itself, that matters here. In research studies following people on a well-formulated low-carb, moderate-protein, high-fat diet with adequate calories, there has been no occurrence of low thyroid. And as long as the calories are not restricted on a very low-carb diet, thyroid and metabolic function remain normal, without any need for consuming additional glucose.

In response I just want to direct your attention to this study, where they took 6 healthy individuals and placed them on an isocaloric ketogenic diet and then measured their thyroid levels after 4 days.  They found a significant decrease in T3 and a significant rise in Reverse T3.  They ate the same amount of calories and their thyroid markers still took a hit.  So to say that there has been ‘no occurrence of low thyroid’ in the setting of adequate calories isn’t entirely true.  Of course this study only lasted 4 days, and ketoadaptation requires a minimum of 3-4 weeks, so the results need to be taken with a grain of salt, but the data can’t be ignored.

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The reason this bothers me so much is because this is also what I’ve seen with my own personal experience about which I’ve written quite extensively.

Here is a short summary: In the midst of my 90 day Nutritional Ketosis experiment (you can also read about the first 60 days here), I tested my blood and was surprised to find that my TSH was at the upper limits of normal at 4.35 (normal 0.45-4.5) and my Free T3 was at the lowest limits of normal at 2.1 (normal 2.0-4.4). Since that was the first time I measured my Free T3 I didn’t have anything to compare it to, BUT I DID have a prior TSH of 1.33 from a blood test just 5 months prior.  The only thing I changed in the interim was starting a ketogenic diet.

Now you could argue that this could’ve all been due to me not eating enough calories, especially since I was doing Crossfit and Training BJJ at the time, but after just 30 days of adding in a bit more carbs (because of the keto rash) I got another blood test and my Free T3 increased to 3.1 and TSH decreased down to 1.82.  I was doing the same volume of exercise and eating the same amount of calories, so the only change was the addition of carbs.

Later on in the year I experimented with Kiefer’s Carb Nite and at the end of the 10 weeks, I drew another set of labs, which showed that my Free T3 had slightly decreased to 2.8 and my TSH slightly increased to 2.23.  Since Carb Nite is a cyclic ketogenic diet which entails eating less than 30 gm of carbs per day during the week with only 1 carb re-feed day per week, I was eating less carbs than when I drew my previous test, but definitely more carbs than when I was in strict nutritional ketosis… and you can see there is a pretty clear relationship between the amount of carbs I ate and both my TSH and Free T3.

To finish this story, I then experimented with Kiefer’s Carb Back-Loading protocol which is a targeted ketogenic approach in which I only ate carbs on evenings I weight-lifted.  Since I’d workout 2-3 times per week that meant that I ate carbs 2-3 times that week.  After 8 weeks I drew another set of labs and found that my TSH had dropped to its lowest level yet at 1.18 which would correspond with my pattern thus far… however my Free T3 also dropped back down to 2.1, which I can’t quite explain.

During this entire time I also found that my Reverse T3 has been consistently elevated… and I don’t know quite yet how to explain it.  Maybe it’s all the sleep disruption from my shift work combined with the various ketogenic diets I’ve been messing around with? But there IS something going on there and to simply dismiss it by saying that it’s all due to insufficient calories isn’t painting the entire picture.

Now I can’t say for certain that ketosis causes hypothyroidism, but all I’m saying is that we can’t be certain that it doesn’t!  More research needs to be done.  There are enough anecdotal reports out there (me, Ben Greenfield, and lots of folks on the internets) to show that this is a legitimate issue and warrants further investigation… and to at least raise a certain level of caution for people who are curious about ketogenic diets but already have a history of hypothyroidism. If you’d like to read some of my other thoughts on this matter you can read this post.

A Few Smaller Issues

While I still think this is the most comprehensive resource available on this subject geared towards the general population, there were a few things that he completely skipped over that I think would have made this better.

No mention of the keto rash at all! This is a topic that is near and dear to me.  We have enough experience with this now to know that it’s a real thing.  There are actual articles in scientific journals written about this to support all the anecdotal evidence out there on the internet (and in my own personal case). Of all the people that read Keto Clarity, we know that good fraction will decide to try the ketogenic diet out for themselves.  We also know that a certain percentage of these people will then find themselves with a mysterious new itchy rash that only appears when they’re ketosis.  Not warning them ahead of time is a disservice. Now I don’t blame Jimmy for not including this since this is still a rare skin condition and not many people know about it so at this point all I can do is continue to plug the website I created for everything keto rash related at www.theketorash.com.

No warning that ketosis can trigger false positives on breathalyzers. This doesn’t occur with ALL alcohol breathalyzers, but it does occur in SOME of them.  I know that I was surprised when I discovered this and I think it’s a fair issue to warn readers about.  Since he’s going to bring up using a breath acetone meter like the Ketonix to measure ketone status, it wouldn’t have been too difficult to also include a sentence cautioning that the presence of breath acetone when in ketosis can trigger false positives in alcohol breathalyzers.

Not enough about the relationship between ketosis and elevated cholesterol.  This is actually one of the biggest concerns keto dieters encounter, and not a single day goes by without someone posting their labs on a message board, forum, or Reddit where they are bewildered and alarmed about their cholesterol.  Jimmy dedicates less than a page to this issue and simply says that ketosis CAN causes your LDL-C to increase, total cholesterol to increase, and LDL particles to shift to the “more benign large, fluffy kind.”  Then he refers the reader to Cholesterol Clarity. I was hoping he would’ve dedicated a little more on this subject since this is a tremendous source of fear and anxiety.  I mean LDL-C and LDL-P can not only go high… but STRATOSPHERICALLY high! This happened to Jimmy himself AND in Franiziska Spritzler, one of the experts in Keto Clarity.

He also never addresses what happens when ketosis actually causes in INCREASE in the less benign, more scary, small dense LDL-P particles, like in my case… and in others on the internets.  I know that the science isn’t complete yet and there’s no clear answer as to what all this means, so that may have played a role into what was kept in the final draft. I also understand that this book is meant for the general population so it might’ve been too much for him to go into how APO E genotypes affect cholesterol levels and other risk factors especially in the setting of high saturated fat consumption OR new tests like the measurement of blood Lathosterol and Campesterol and how they relate to elevated LDLs… but for folks that have been into this for a while like myself, a section on this stuff would’ve been nice.

Final Thoughts

Aside from these few issues which are relatively small in the scheme of things, I can’t say enough good things about Keto Clarity.  It’s the most comprehensive, easy to read resource available on this subject.  I’m glad I bought it and I wouldn’t hesitate to recommend to to anyone interested in this way of eating. I seriously wish this were available years ago when I first started my journey down this path since it would have saved a lot of time and effort spent searching for more information on topics that he provides in one handy dandy book. Thanks for reading my Keto Clarity Book Review. You can buy it here from Amazon: Keto Clarity: Your Definitive Guide to the Benefits of a Low-Carb, High-Fat Diet

UPDATE (11/12/14, 1:20 pm)

I’m constantly amazed at technology these days.  Within a few minutes of sending this link out to Jimmy he responded via twitter!  How cools is that?  That I could have direct correspondence with an author about a review I wrote moments after this was published.  Simply amazing. Jimmy was more than happy for me to publish our discussion.  Here were his responses to some of the issues I brought up:

Protein and Satiety

@bjjcaveman Interesting thoughts and balanced review. THANK YOU! My response to your concerns–very aware of studies on protein’s satiety… — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman …but because of gluconeogenesis that happens especially in the insulin resistant, it can stoke hunger and cravings like carbs. — Jimmy Moore (@livinlowcarbman) November 12, 2014

Keto and Hypothyroidism

@bjjcaveman The hypothyroidism one has not been fully investigated by any randomized, controlled trial and never with an adequate calorie… — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman …ketogenic diet. I do think calories is the key and this needs to be thoroughly studied before any proclamations it’s a fact. — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman Many underlying thyroid issues that already exist pre-keto can manifest themselves once someone starts eating low-carb, high-fat — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman But that doesn’t mean LCHF was root cause of the problem. Also, it’s very easy to UNDEReat on keto because of appetite control. — Jimmy Moore (@livinlowcarbman) November 12, 2014

 

Keto Rash

@bjjcaveman On keto rash, I talked to Dr. Westman & ALL of my practitioner friends using ketogenic diets with patients–NONE reported this. — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman I understand your passion about this, but in a mainstream book with a publisher they would want some kind of proof of claims. — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman I’m not saying it doesn’t happen and I’ve read your great blog about it. Unfortunately, it’s not an overwhelming problem to note — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman Our best theory for why it happens is perhaps a food allergy or something like that. But most people going keto don’t have this. — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman Perhaps. Other than you & I think one other person why emailed me, I’ve never heard of this happening as a result of going keto. — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman I didn’t have any widespread anecdotes to share. It’s not that I didn’t want to share info, but not relevant to general public. — Jimmy Moore (@livinlowcarbman) November 12, 2014

Keto and Cholesterol

@bjjcaveman I hear you on the cholesterol stuff and my publisher said to reference Cholesterol Clarity for people wanting to learn more. — Jimmy Moore (@livinlowcarbman) November 12, 2014

Ben Greenfield

 

@bjjcaveman @dietitiancassie Cassie will be in touch when we start recording again. As for Ben, I’m aware of his issues, but he didn’t… — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman …emphasize them in my interview with him for the book. If they were a bigger issue, I would think he might articulate them. — Jimmy Moore (@livinlowcarbman) November 12, 2014

@bjjcaveman That said, he was doing it under the auspices of exercise performance which is far different from the average Joe or Jane. — Jimmy Moore (@livinlowcarbman) November 12, 2014

Invitation to go on the Low-Carb Conversations Podcast!

@bjjcaveman THANKS again for a fantastic review! I appreciate you bud & we gotta get you on Low-Carb Conversations in 2015. @DietitianCassie — Jimmy Moore (@livinlowcarbman) November 12, 2014

  I understand the reasoning behind all of his responses.  With the whole Ben Greenfield thing, it was like I suspected, he just wasn’t aware of Ben’s issues. I’m not completely satisfied with his response to the protein and satiety thing, I mean if you eat 16 oz of rib eye, I don’t care how much gluconeogenesis there is because I guarantee you WILL NOT be hungry for quite some time (although in all fairness, there’s a good amount of fat in rib eye). I’m also not completely satisfied with his response to the hypothyroidism thing, I mean my labs showed I clearly didn’t have any hypothyroid issues prior to going into ketosis.  I think there’s still enough anecdotal evidence out there along with that study I cited, to indicate that there IS a relationship.  I’m also not aware of any randomized, controlled trials showing that ketosis DOESN’T cause hypothyroidism. All in all, we don’t have to agree with each other on everything.  I’m still glad Jimmy wrote the book and am actually rooting for his success, and I definitely appreciate his willingness to have a discussion with me on these issues. Like I said before in my disclosure, I LIKE Jimmy.