Ketogenic WOE for Health and Weight Management: Implications for Lymphedema and Lipedema

Catherine Seo, PhD & Leslyn Keith, OTD

Dr. Peter Attia ( uses the analogy of a bar crowded with people.  If you say the bar is crowded because more people went in than went out, you are factually correct, but you have given no information as to why the bar is crowded, you’ve merely restated the issue.  True but useless - a classic tautology.

Saying the bar is crowded because more people went in than went out is identical to saying someone is overweight because they took in more calories than they expended.  In the case of the bar, it might be crowded because the movie theater next door just let out, the bar is having two for one drinks, or any number of other reasons.  So, too, must there be an underlying reason for someone to gain weight. Research suggests that what we’ve thought of as caloric balance and energy expenditure is even more complex than originally touted.

Calories In Calories Out (CICO)

There are many reasons a person might become overweight or obese.  A small portion of the myriad reasons for gaining weight includes medications, food quality, hormone levels, or diseases such as tumors.   In the case of a woman with a pituitary tumor, diagnosis and excision of the tumor will remove the cause of weight gain.  In this case, if the patient had just been told that she was getting fat because she was taking in more calories than she was expanding, no satisfactory relief could be obtained.

Another issue with using the idea of Calories In, Calories Out (CICO) is the fact that a calorie is not a physical object.  A calorie is only the defined representation of the energy state of a food item.  People don’t eat calories.  People eat food.  Different foods exert different effects on people, with or without regard to any food item’s level of available energy, or “calorie” for short.


Here’s where you might think it gets a bit tricky, but please follow along.  All foods are made up of only three possible macronutrients (macro).  These are carbohydrate, protein, and fat.  Each macro has certain levels of energy (calories).  From studies done over 100 years ago, validated many times since, all carbohydrates have 4 calories per gram, all proteins have 4 calories per gram and all fats have 9 calories per gram.  At this point, one might think that eating a certain amount of grams of carbohydrates and protein would cause less weight gain than eating that same amount of fat.  This is a common misconception and it is the basis of the nutritional guidelines of many countries, and is, in the main, the essence of the bad nutritional advice we have been given over the past five or so decades.  It is also the faulty notion on which low-fat diets were, and still are, foisted on the public.

Protein, Carbohydrates & Fat

Remember, we said different foods exert different effects on people?  This is where the effects that macronutrients have on the human body influence whether that body gains weight, loses weight or remains weight stable.  The most common etiology of weight gain in the developed world is a carbohydrate-heavy diet.

Proteins are essential (meaning they must be eaten periodically to remain healthy), build structure such as muscle and bone, contribute molecules for hormones, and are an energy source.  Fats, also essential, are substrates for hormones, become parts of cell membranes, and are also an energy source.  Carbohydrates, on the other hand, break down into glucose and are only used for energy.

Carbohydrates are not essential nutrients.  According to the US Institute of Medicine Dietary Reference Intakes (2008) “The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed.”  We can get all essential micronutrients (vitamins and minerals) from fat and protein sources, and through the process of gluconeogenesis, our bodies can make all of the glucose we need.

What Nutrition Do We Really Need?

Why should macronutrients be of concern when considering weight loss?  Upon ingestion, fat elicits an insignificant secretion of the hormone insulin, while protein causes a greater amount of the hormone to be released.  Carbohydrate, however, triggers the highest insulin response, nearly 50% higher than the same amount of protein and vastly greater amounts than fat.  Insulin’s job is to protect the body from high blood sugars (glucose).  It does so by forcing the glucose into available cells where it is stored in the form of glycogen or fat. Insulin may also ferry glucose to the liver where the glucose is converted into fat, and then sent to the adipose tissue for storage in fat cells (adipocytes).

The human body has a narrow tolerance for the amount of glucose in the blood.  Insulin maintains this level at about 2 teaspoons in our entire bloodstream.  Levels higher than this constitute an emergency and the quickest way for insulin to rid the bloodstream of glucose is to use it for energy, to the exclusion of all other energy sources, or to push the glucose into storage by moving it into adipocytes.

This shutting down of fat burning is the main mechanism for weight gain.  Fat ingestion does not elicit an insulin response; therefore, fat burning is not shut down.  Eating fat allows your body to continue to burn your own fat as well as the fat you eat, without a hitch.  Consuming protein causes about half the insulin response as carbohydrate, but protein is not usually eaten in the high amounts that carbohydrates are.  And we are not advocating a high consumption of protein.

All people are continually using (burning) fats or glucose for energy.  Sometimes more fat is being used.  Other times more glucose is being burned.  The master moderator for determining which one will be used is insulin.  The only way to keep insulin low is to consume fat for energy.  This is the basis for the ketogenic diet, which is succinctly defined as Low Carbohydrate, High Fat, Moderate Protein.

Why Low Carb/High Fat Makes a Difference

The old paradigm of energy balance which is based on the non-reasoning of CICO is giving way to the hormonal theory of weight gain.  The sorry story of how energy balance became the hypothesis du jour and fat became regarded as bad is well documented in Gary Taubes’s exhaustively researched book Good Calories, Bad Calories and in Nina Teicholz’s excellent book The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet.

Since fat does not increase insulin, eating fat allows continuous fat burning.  This is why, when you eat a well-formulated ketogenic diet, your energy does not flag at any time around the clock, not even after meals.  Your blood sugar remains low, but your energy remains high.  You lose weight without hunger.  Instead of the deprivation common to most weight-loss diets, you feel satiated, energetic, and indulged.

Ketogenic WOE: Challenges, Successes, and Support for Change

Even armed with rock-solid science, giving up your favorite foods and adopting a completely new way of eating can be a challenge.  Mutual encouragement and support can be an important element of success, especially for those who have struggled so valiantly with oftentimes little or no results as happens with lymphatic disorders and especially lipedema. One of the lipedema ladies who joined our online classes and group reported to us:

“Today was weigh and measure day with my sister. We were both pleasantly surprised with my results! This past month I have lost 11.8 pounds, but the big shocker was I have lost 20 inches!!! Amazing! A couple of things I have noticed this past month are that my feet are no longer cold most of the time, and my thin wool socks now feel much cozier and I no longer have to take a foot warming hot water bottle to bed every night. How weird is that!! My upper arms (not at the bicep level but more at the top closer to the shoulder) have gone from feeling quite hard to very soft. I was at my doctor's office last week, just for prescription renewal. She commented that I had lost weight. She thought I had lost 50 lbs when I really have only lost about 30 lbs, so all those inches lost were much more visible than I thought. This keto life is very good!” ~Betty C., Canada

Our next article in this series will discuss how the support of your family, friends, and medical providers can be indispensable and make all the difference in health, well-being, and overall satisfaction with these new lifestyle choices.