Is It Hard to Follow? -Ketogenic Diet Adherence

Is It Hard to Follow? -Ketogenic Diet Adherence

Can I do it? Is a question many may ask themselves before starting a diet. The ketogenic diet, known for its stringent restriction on carbohydrate intake and emphasis on high amounts of fat,1–3 is a diet that may especially pose a challenge. For many seeking to reap its benefits in weight loss and metabolic health, it may be beneficial to learn of its potential challenges before starting the diet. What are the barriers to following a ketogenic diet, and how can you overcome them?


What Is the Adherence Rate for the Ketogenic Diet?

The ketogenic diet is known for its effectiveness in promoting weight loss and improving metabolic health, but adherence is a key challenge.4 Adherence to dietary plans and guidelines is especially important for those with metabolic conditions for improved health.5 However, studies generally report low levels of adherence to the ketogenic diet.6–8 Most studies show that only half of adults are able to follow through with the diet, with rates ranging from 9.5% to 98% based on different study designs. Individuals who drop out of the ketogenic diet often cite side effects, restrictiveness of the diet, and psychosocial stressors as key obstacles. 


What Are the Barriers & How Do You Overcome Them?

Keto Flu – “Keto flu” is a conglomerate of short-term symptoms including fatigue, headache, dizziness, nausea, gastrointestinal discomfort, and decreased energy.4 It is commonly experienced during the initial period of adjustment, but can greatly hinder adherence to the diet in the long-term.9,10 Being aware that the ketogenic diet may come with short-term discomforts can help continue with the diet when faced with initial difficulties. Ensuring adequate fluid, electrolyte, and nutritional intake during the adjustment periods can also be crucial.


Cultural Barriers – Most culture’s diets are not heavily based on fat and protein and can make following the ketogenic diet difficult.6 For instance, Asian diets are typically carbohydrate-rich, being high in rice, noodles, potatoes, and flatbreads. Traditional Hispanic diets are also rich in carbohydrates such as rice, beans, and tortillas. Additionally, the Middle Eastern and North African region largely consume what is well-known as the Mediterranean diet rich in fibers and vegetable proteins. People’s preferences and cultural ties to foods can make it a challenge to follow the ketogenic diet. Studies show that when individuals adapt to dietary plans contrary to their traditional diets, joining community groups and receiving social support can be vital to overcoming cultural barriers.11 Additionally, reading about and experiencing the successes of the ketogenic diet can encourage individuals to start as well as to follow through with dietary plans that may go against their cultural or ethnic food preferences.12 


Cost – It is generally true and a widely accepted premise that the ketogenic diet is more expensive than high-carbohydrate eating patterns.6 Studies find that low-carbohydrate diets to indeed be more costly, some finding that the cheapest possible low-carbohydrate diet to be three times more expensive than the cheapest diet that has no carbohydrate restriction.13 However, thoughtful meal planning and looking for deals can help reduce the cost of the diet significantly. One descriptive case study designed two diets (a low-carbohydrate diet and a diet based on New Zealand national nutrition guidelines) for a hypothetical family of four and found that the daily cost difference to be $8.25, or $2.06 per person, concluding that this difference may be negligible.14 The study continues to suggest that making conscious choices on the types of fat, protein, and vegetables can make a substantial change to the cost of low-carbohydrate diets. For instance, extra virgin oil, macadamia nuts, fresh salmon, and broccoli commonly consumed in low-carbohydrate diets can be substituted with their less costly nutritional equivalents such as standard olive oil, linseed, sardines, and frozen spinach.


1. Masood W, Annamaraju P, Uppaluri KR. Ketogenic Diet. In: StatPearls. StatPearls Publishing; 2022. Accessed August 9, 2022.
2. Alarim RA, Alasmre FA, Alotaibi HA, Alshehri MA, Hussain SA. Effects of the Ketogenic Diet on Glycemic Control in Diabetic Patients: Meta-Analysis of Clinical Trials. Cureus. 12(10):e10796. doi:10.7759/cureus.10796
3. Yuan X, Wang J, Yang S, et al. Effect of the Ketogenic Diet on Glycemic Control, Insulin Resistance, and Lipid Metabolism in Patients With T2DM: a Systematic Review and Meta-analysis. Nutr Diabetes. 2020;10(1):1-8. doi:10.1038/s41387-020-00142-z
4. Cogen FR. Incorporation of the Ketogenic Diet in a Youth With Type 1 Diabetes. Clin Diabetes. 2020;38(4):412-415. doi:10.2337/cd20-0023
5. Al-Salmi N, Cook P, D’Souza MS. Diet Adherence among Adults with Type 2 Diabetes Mellitus: A Concept Analysis. Oman Med J. 2022;37(2):e361. doi:10.5001/omj.2021.69
6. Kumar NK, Merrill JD, Carlson S, German J, William S Yancy J. Adherence to Low-Carbohydrate Diets in Patients with Diabetes: A Narrative Review. Diabetes Metab Syndr Obes. 2022;15:477. doi:10.2147/DMSO.S292742
7. Ye F, Li XJ, Jiang WL, Sun HB, Liu J. Efficacy of and Patient Compliance with a Ketogenic Diet in Adults with Intractable Epilepsy: A Meta-Analysis. J Clin Neurol. 2015;11(1):26-31. doi:10.3988/jcn.2015.11.1.26
8. Li S, Du Y, Meireles C, et al. Adherence to Ketogenic Diet in Lifestyle Interventions in Adults with Overweight or Obesity and Type 2 Diabetes: A Scoping Review. Nutr Diabetes. 2023;13:16. doi:10.1038/s41387-023-00246-2
9. Lichtash C, Fung J, Ostoich KC, Ramos M. Therapeutic Use of Intermittent Fasting and Ketogenic Diet as an Alternative Treatment for Type 2 Diabetes in a Normal Weight Woman: a 14-Month Case Study. BMJ Case Reports CP. 2020;13(7):e234223. doi:10.1136/bcr-2019-234223
10. Bostock ECS, Kirkby KC, Taylor BV, Hawrelak JA. Consumer Reports of “Keto Flu” Associated With the Ketogenic Diet. Front Nutr. 2020;7:20. doi:10.3389/fnut.2020.00020
11. Corciolani M. Navigating Institutional Complexity Through Emotion Work: The Case of Italian Consumers Adapting to a Ketogenic Diet. J Bus Res. 2023;158:113657. doi:10.1016/j.jbusres.2023.113657
12. Seo JH, Kim HD. Cultural Challenges in Using the Ketogenic Diet in Asian Countries. Epilepsia. 2008;49(s8):50-52. doi:10.1111/j.1528-1167.2008.01834.x
13. Raffensperger JF. The Least-Cost Low-Carbohydrate Diet Is Expensive. Nutrition Research. 2008;28(1):6-12. doi:10.1016/j.nutres.2007.10.002
14. Zinn C, North S, Donovan K, Muir C, Henderson G. Low‐carbohydrate, healthy‐fat eating: A cost comparison with national dietary guidelines. Nutr Diet. 2020;77(2):283-291. doi:10.1111/1747-0080.12534



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