Keto diet with Pakistani food: what the evidence says.

What is the keto diet?

Keto, short for ketogenic, is a high-fat, very low-carbohydrate diet with a moderate amount of protein. With so little carbohydrate coming in, your body shifts from using glucose (sugar) for energy to using ketones, which the liver makes from fat.

The version used for weight loss usually limits carbohydrate to 20 to 50 g a day, with 60 to 75% of calories coming from fat, according to a StatPearls medical review listed on PubMed. For comparison, a single roti made from 40 g of atta has about 29 g of carbohydrate.

Keto began as a treatment for epilepsy in the 1920s, and epilepsy is still the only use with broad backing from medical guidelines. Trials show it can help some people with weight and blood sugar, but for those uses the same review still calls it investigational, without guidelines from professional medical bodies.

How many carbs are in roti, rice and daal?

More than most people expect, which is why keto changes a Pakistani plate so much. One roti and a katori (small bowl) of daal already add up to more than the top of the keto range.

Figures are total carbohydrate, including fibre, rounded from USDA FoodData Central. On strict keto, daal and chana go along with roti and rice, even though they're useful sources of protein and fibre in a Pakistani kitchen.

What can you eat on a Pakistani keto diet?

Protein and low-carb sabzi, cooked in fat. A Pakistani keto day can still taste like home; what goes missing is the roti.

• Eggs: boiled, as an omelette with onion, tomato and green chilli, or as khageena (spiced scrambled eggs).
• Meat and fish: chicken or mutton karahi, chicken tikka, seekh kebab or grilled fish, without the naan.
• Paneer: palak paneer, paneer tikka or paneer bhurji.
• Sabzi: palak, bhindi, gobhi, lauki, tori, karela and baingan, plus a kachumber salad of cucumber, tomato and onion.
• Small amounts: dahi, and nuts such as almonds and walnuts.

Out go roti, rice, naan, daal, chana, aloo, most fruit, mithai and sugar in chai. That's the hard part in a Pakistani home, and harder still at a dawat (a meal at someone's home) or a shaadi, where biryani, naan and dessert are the main event.

Watch the fat, too. Keto doesn't have to mean karahi swimming in ghee or butter in your chai. The WHO advises getting no more than 10% of daily energy from saturated fat, and ghee, butter and malai are rich in it. Cook with a measured amount of plant oil, and see our heart-healthy Pakistani diet for more.

Is keto better than other diets for weight loss?

Not by much. Keto can help some people lose weight, but so can other diets that cut calories, and in trials lasting a year the difference is small.

A well-known test is the DIETFITS trial, published in JAMA in 2018. It randomly assigned 609 adults aged 18 to 50, without diabetes and with a BMI of 28 to 40, to a healthy low-carb or a healthy low-fat diet for 12 months. Both groups were coached to eat good-quality food. After a year, the low-carb group had lost an average of 6.0 kg and the low-fat group 5.3 kg, a difference that wasn't statistically significant.

The trial also tested whether people's genes, or how much insulin they made after a glucose drink, could predict which diet would suit them. Neither did. By the end, the low-carb group was getting about 30% of its energy from carbohydrate, well above the 5 to 10% typical of keto.

For keto itself, a 2013 analysis of 13 trials lasting a year or more compared very low-carb diets (no more than 50 g of carbohydrate a day) with low-fat diets. People on the low-carb diets lost slightly more weight, just under 1 kg more on average. Their triglycerides fell and HDL ('good') cholesterol rose, but LDL cholesterol rose slightly too.

As the DIETFITS authors note, no single diet is consistently better than the others for everyone. The one you can keep up matters more than its name.

What are the side effects of keto?

The best-known ones come early, in the first few weeks, and are often called 'keto flu'. A 2020 study of online forum posts about it found the most common complaints were flu-like feelings, headache, tiredness, nausea, dizziness, 'brain fog', stomach discomfort, low energy, feeling faint and changes in heartbeat. Reports peaked early and faded after about four weeks.

Other things to watch:

• Less fibre. With daal, chana, whole wheat atta and most fruit gone, you lose some of your main sources of fibre, so pile on the sabzi and salad.
• Cholesterol. LDL cholesterol rose slightly on average in the keto trials above, and Pakistani keto cooking can lean heavily on ghee, butter and cream. If you already have high cholesterol, check with your doctor first.
• Family meals. Eating separately every night and turning down roti at every dawat is hard to keep up for months.

Who should not try keto without a doctor?

Keto is a big change, so some people need medical advice before they start. Talk to your doctor first if you:

• take insulin or diabetes tablets such as gliclazide, because cutting carbohydrates suddenly can make your blood sugar drop too low, and your doses may need to change;
• are pregnant, trying for a baby or breastfeeding;
• have kidney problems;
• have had an eating disorder, or find that strict food rules make you anxious;
• have high cholesterol or heart disease, or take other regular medicines.

Never stop or reduce a medicine on your own, even if your readings improve. If you're expecting, our pregnancy diet guide covers eating well for you and your baby. And you don't need keto pills, ketone drinks or 'keto' powders. Keto is a way of eating, not a product.

Is there a gentler low-carb diet with Pakistani food?

Yes, and for most people it's easier to live with. Instead of cutting carbohydrate to keto levels, you eat less of it, choose better sources and build the rest of the plate around protein and sabzi.

• Make the roti smaller. A roti made from 30 g of atta has about 22 g of carbohydrate, against about 29 g for one made from 40 g. Our guide to roti and weight loss shows how to weigh your pera (dough ball) once.
• Have roti or rice, not both. Keep it to a quarter of the plate, as in the US CDC plate method, with half the plate sabzi and a quarter protein.
• Keep daal and chana. They bring protein and fibre. Count a katori of daal as part of that meal's carbohydrate.
• Cut sugar first. Sugar in chai, cold drinks, packaged juice and mithai is the easiest carbohydrate to drop, because you don't lose a meal.
• Put protein in every meal: eggs at breakfast, chicken, fish or daal at lunch, and dahi or paneer at dinner.

If you have insulin resistance or diabetes, our guides to the insulin resistance diet and the diabetic diet plan show how to set roti and rice portions, and you can see how we work with blood sugar and weight.

NutriZaika is a virtual nutrition clinic. Our 28-day plans set calories and carbohydrate for your body and health, with every ingredient in grams, and each plan is reviewed by Nida Tu Sehar, Senior Nutrition Consultant and Clinical Lead. See our plans and prices or our online weight loss clinic, and if you'd like a plan built around your own kitchen, choose your plan.