The ketogenic diet (keto diet) is a low-carbohydrate, high-fat dietary strategy designed to shift the body’s metabolism toward ketosis, a state where fat becomes the primary energy source instead of carbohydrates. Initially developed as a medical intervention for epilepsy, keto has gained significant attention for its potential benefits in fat loss, metabolic health, and cognitive function.
For transgender individuals undergoing hormone replacement therapy (HRT) or testosterone replacement therapy (TRT), diet plays a crucial role in hormonal balance, body composition, and overall well-being. Since dietary fat supports hormone production and absorption, a properly structured high-fat ketogenic approach can offer unique advantages.
Having personally followed keto-style diets since the 1990s, starting with the Atkins Diet, I’ve seen firsthand how nutritional ketosis can aid in fat loss, muscle retention, and energy stability. Before my transition, I was a competitive bodybuilder and used keto during the final weeks of show preparation to achieve peak muscle definition while maintaining lean mass. Later, as a fitness coach, I helped clients integrate keto into their daily routines for fat loss, performance enhancement, and metabolic health.
This article offers a science-based yet compassionate perspective on how the keto diet may support or impact transgender individuals, including key keto diet tips, what to expect when starting keto, how to incorporate cheat meals, and what happens when reintroducing carbohydrates after reaching a goal weight.
Understanding the Keto Diet
The ketogenic diet follows a high-fat, moderate-protein, and low-carbohydrate macronutrient structure:
- 70-80% fat
- 15-25% protein
- 5-10% carbohydrates (typically under 50g net carbs per day)
How the Keto Diet Works
By drastically reducing carbohydrate intake, the body depletes glycogen stores and begins producing ketones from fat, shifting into ketosis. This metabolic adaptation provides several benefits:
- Accelerated fat loss while maintaining lean muscle
- Steady energy levels without insulin crashes
- Improved cognitive function and mental clarity
- Reduced inflammation and oxidative stress
During my bodybuilding years, I found keto invaluable for cutting fat without sacrificing muscle mass, making it an essential tool for body recomposition.
Low-Carb/High-Protein vs. Low-Carb/High-Fat: What’s the Difference?
Not all low-carb diets are the same. There are two primary variations, each with distinct metabolic effects:
Low-Carb/High-Protein (Not Keto)
- Typically 50-150g carbs per day
- Higher protein intake (30-40%), moderate fat intake
- Common in high-protein diets like Atkins, Paleo, and Carnivore
- May cause gluconeogenesis, where excess protein is converted into glucose
This approach can be beneficial for bodybuilders and strength athletes who need extra protein for muscle recovery. However, if protein intake is too high, it may interfere with ketosis because the body will convert excess protein into glucose, reducing reliance on fat for energy.
⚠️ This version is not ideal for maintaining ketosis.
Low-Carb/High-Fat (Ketogenic Diet)
- <50g net carbs per day
- Moderate protein (15-25%), high fat (70-80%)
- Encourages ketosis, where the body burns fat instead of glucose
This is the true ketogenic diet, which optimally supports hormone production and fat adaptation. It is particularly beneficial for transgender individuals on HRT/TRT due to fat’s role in hormone regulation.
What to Expect When Starting a Keto Diet
Switching to keto is a big adjustment, and your body will go through several changes as it transitions into ketosis. Understanding these changes can help you prepare for the adaptation period.
Keto Flu (Temporary Discomfort)
Some people experience flu-like symptoms during the first week as the body shifts from burning glucose to burning fat.
Common Symptoms:
- Fatigue
- Headaches
- Muscle cramps
- Nausea
- Brain fog
✅ How to Minimize Keto Flu:
- Stay hydrated (drink at least 2-3 liters of water daily).
- Consume electrolytes (sodium, potassium, magnesium).
- Eat more healthy fats to encourage ketosis.
Increased Thirst & Frequent Urination
When you reduce carbs, your body releases stored glycogen, which holds water. This leads to increased urination and temporary water weight loss.
Signs You Are in Ketosis
There are several ways to monitor ketosis, either through physical signs or testing ketone levels.
Physical Signs of Ketosis:
- Increased Energy – After the initial adjustment, many feel more energetic.
- Reduced Hunger & Cravings – Keto can naturally suppress appetite.
- Mental Clarity – Ketones are a more efficient fuel source for the brain.
- Fruity or Metallic Breath – Acetone (a type of ketone) is released through the breath.
- Improved Fat Loss – A steady, noticeable decrease in body fat.
Ways to Measure Ketone Levels:
- Urine Strips – Inexpensive but less accurate over time.
- Blood Ketone Meters – More precise but requires finger-pricking.
- Breath Meters – Measures acetone levels for a non-invasive option.
Carbs vs. Net Carbs: What’s the Difference?
One of the most common misconceptions about the keto diet is carbohydrate counting. There’s a critical difference between total carbs and net carbs that significantly impacts ketosis.
Total Carbs vs. Net Carbs
- Total Carbs = All the carbohydrates in a food item, including fiber and sugar alcohols.
- Net Carbs = Total Carbs – Fiber – Sugar Alcohols (like erythritol)
Since fiber and some sugar alcohols don’t raise blood sugar or insulin, they don’t count toward your effective carb intake on keto.
Example:
- Avocado (1 medium) → 12g total carbs, but 9g fiber
Net carbs = 3g - Chia Seeds (1 oz) → 12g total carbs, but 10g fiber
Net carbs = 2g
Focusing on net carbs allows you to enjoy fiber-rich, nutrient-dense foods without being overly restrictive.
How the Keto Diet Affects Transgender Individuals on HRT/TRT
For trans individuals, dietary choices can impact hormone levels, metabolism, and body composition. Here’s how keto may affect those undergoing HRT (estrogen + anti-androgens) or TRT (testosterone therapy).
Keto & MTF Transgender Women (HRT)
For trans women on estrogen and anti-androgens, keto can have several effects:
- Body Fat Distribution: Estrogen promotes fat storage in the hips, thighs, and breasts. Since keto promotes fat loss, it may reduce stored fat, including in traditionally feminine areas.
- Hormone Absorption: Since estrogen is fat-soluble, dietary fat intake can influence hormone absorption. Consuming healthy fats (avocados, olive oil, fatty fish) supports hormonal balance.
- Insulin Sensitivity & PCOS Symptoms: Some trans women have PCOS-like symptoms due to higher androgen levels. Keto reduces insulin resistance, which can help with hormonal stability.
Keto & FTM Transgender Men (TRT)
For trans men on testosterone replacement therapy (TRT), keto may enhance their fitness goals:
- Increased Muscle Mass: Testosterone increases lean muscle, and keto (with adequate protein intake) supports muscle retention.
- Improved Insulin Sensitivity: Many trans men struggle with insulin resistance, and keto can stabilize blood sugar.
- Higher Energy Levels & Strength Gains: Keto can provide steady energy for strength training, making it easier to build muscle and reduce fat.
Warning Signs & When to Consult a Medical Professional
While I have not personally experienced many issues with keto flu, I acknowledge that some individuals may experience challenges when transitioning to ketosis. Understanding the warning signs can help determine if adjustments or medical guidance are needed.
Common Side Effects (Usually Temporary)
Keto Flu Symptoms:
- Fatigue, dizziness, and brain fog
- Muscle cramps or weakness
- Headaches
- Nausea or digestive upset
Solution:
- Drink plenty of water and increase electrolyte intake (sodium, potassium, magnesium).
- Eat electrolyte-rich foods such as avocados, nuts, and leafy greens.
When to Consult a Medical Professional
Potential Warning Signs:
- Persistent fatigue or extreme lethargy lasting beyond the first few weeks
- Heart palpitations or irregular heartbeat
- Severe muscle loss or weakness
- Hormonal imbalances (missed periods, low libido, mood swings)
- Worsening anxiety or depression
Solution: If you experience these symptoms, consider consulting a doctor, endocrinologist, or nutritionist to evaluate potential nutrient deficiencies or metabolic adjustments.
RELATED: Evaluating Your HRT Journey: Goals, Progress, and Adjustments
What to Expect When Starting a Keto Diet
Switching to keto is a big adjustment, and your body will go through several changes as it transitions into ketosis. Understanding these changes can help you prepare for the adaptation period.
Keto Flu (Temporary Discomfort)
Some people experience flu-like symptoms during the first week as the body shifts from burning glucose to burning fat.
Common Symptoms:
- Fatigue
- Headaches
- Muscle cramps
- Nausea
- Brain fog
How to Minimize Keto Flu:
- Stay hydrated (drink at least 2-3 liters of water daily).
- Consume electrolytes (sodium, potassium, magnesium).
- Eat more healthy fats to encourage ketosis.
Increased Thirst & Frequent Urination
When you reduce carbs, your body releases stored glycogen, which holds water. This leads to increased urination and temporary water weight loss.
Signs You Are in Ketosis
There are several ways to monitor ketosis, either through physical signs or testing ketone levels.
Physical Signs of Ketosis:
- Increased Energy – After the initial adjustment, many feel more energetic.
- Reduced Hunger & Cravings – Keto can naturally suppress appetite.
- Mental Clarity – Ketones are a more efficient fuel source for the brain.
- Fruity or Metallic Breath – Acetone (a type of ketone) is released through the breath.
- Improved Fat Loss – A steady, noticeable decrease in body fat.
Ways to Measure Ketone Levels:
- Urine Strips – Inexpensive but less accurate over time.
- Blood Ketone Meters – More precise but requires finger-pricking.
- Breath Meters – Measures acetone levels for a non-invasive option.
Tips for Following a Healthy Keto Diet
A well-structured keto diet is more than just cutting carbs—it’s about choosing the right foods to support long-term health.
Focus on Whole, Nutrient-Dense Foods
- Healthy fats: Avocados, olive oil, nuts, and fatty fish
- High-quality proteins: Wild-caught fish, pasture-raised eggs, and grass-fed meats
- Non-starchy vegetables: Spinach, kale, broccoli, and bell peppers
Avoid Processed “Keto” Snacks
Many “keto-friendly” snacks are heavily processed and contain low-quality ingredients, including:
- Unhealthy seed oils (soybean, canola, sunflower oil)
- Excess sugar alcohols, which may cause digestive distress
- Artificial preservatives and additives
Stick to natural, whole-food alternatives over store-bought keto bars and snacks.
Stay Hydrated & Balance Electrolytes
Since electrolytes are flushed out during keto, make sure to consume:
- Sodium – Add Himalayan salt to meals
- Potassium – Eat avocados, spinach, and salmon
- Magnesium – Include nuts, pumpkin seeds, and leafy greens
Cheat Meals on Keto: When and How to Incorporate Them
Many people wonder if they can occasionally eat carbs while following keto. The answer depends on your goals and metabolic flexibility.
When to Have a Cheat Meal
- After being in ketosis for at least 4-6 weeks
- If your goal is long-term sustainability rather than strict ketosis
- Before a heavy workout if utilizing carb cycling
What to Avoid in a Cheat Meal
- Ultra-processed carbs (white bread, sugary sodas, junk food)
- Excess sugar (syrups, candy, desserts)
- High-carb + high-fat meals (pizza, deep-fried foods, pastries)
Instead, opt for slow-digesting, whole-food carbs like sweet potatoes, quinoa, or berries.
What Happens When You Reintroduce Carbs?
If you decide to transition out of keto or incorporate more carbs while maintaining weight, here’s what to expect:
Water Weight Gain is Normal: Carbohydrates store glycogen, which holds water. Expect an increase of 3-5 lbs in water weight, but this is not fat gain.
Increased Appetite: Carbs can trigger hunger and cravings due to blood sugar fluctuations. Solution: Slowly increase carbs while maintaining protein and fat intake.
Adjusting for Weight Maintenance: If your goal is to maintain weight, try a low-carb or carb-cycling approach:
- 50-100g carbs per day to prevent excessive fat gain
- Focus on whole, fiber-rich carbs (oats, sweet potatoes, fruit)
- Monitor energy levels and performance to adjust intake as needed
The Bottom Line
The keto diet can be an effective tool for fat loss, hormonal balance, and metabolic health, but it requires thoughtful execution. By prioritizing whole, nutrient-dense foods, staying hydrated, understanding the role of cheat meals, and knowing what to expect when transitioning back to carbs, individuals can maximize the benefits of keto while maintaining long-term success.
Medical & Nutrition Disclaimer: The information provided in this article is for educational and informational purposes only and is not intended as medical advice, diagnosis, or treatment. The ketogenic diet and any dietary changes should be discussed with a qualified healthcare professional, registered dietitian, or physician, especially for individuals undergoing hormone replacement therapy (HRT) or testosterone replacement therapy (TRT).
