When news hit that up-and-coming Bollywood actress Mishti Mukherjee died this week at 27 due to complications from a keto diet, according to her family, the world erupted in sadness and shock, as headlines circled the globe from India to England and in the US.  Her fans shuddered at the news. Two things struck anyone reading the story: How young and healthy Mishti appeared, and the fact that a keto diet could cause extreme kidney failure, leading to such a tragic loss.

Keto diets are known to work in the short term to help dieters shed weight by cutting out virtually all carbs–allowing carbs to be just 5 percent of your total intake–and fueling up on fat and protein, which make up 70 percent and 25 percent of total intake. The diet forces the body into ketosis, which is when cells burn fat for fuel, but an overwhelming amount of ketones released in the body can put a strain on the kidneys, which work to filter these byproducts of fat burning, causing kidney stones, loss of function and ultimately kidney failure. Doctors reacting to the news were quick to issue warnings in the wake of Mukherjee's death.

Three specific warnings about keto were issued: One is that while keto appears to be extremely effective in helping overweight or obese people lose weight, it could be dangerous for thin people to do it, since they run the risk of complications from putting their body into ketosis; that the diet must be accompanied by drinking copious amounts of water, to help the kidneys flush out the toxins; and the third is that you should not stay on a keto diet for longer than 45 days, and perhaps not even that long. There are healthy ways to follow a keto diet, that involve eating mostly plant-based foods, experts say, but most keto fans prefer to eat processed meat such as bacon to help push up their fat and protein intake to the levels required.

Keto is Not Unhealthy In Itself, It's How You Go Keto That Poses a Potential Health Risk

Keto diets are not unhealthy, it's the way people do them that is, according to Dr. Andrew Freeman, the cardiologist at National Jewish in Denver, recently released a study that keto dieting can lead to heart disease because of the foods people eat while on the diet: People often load up on red meat, processed meat like bacon, and stay away from healthy plant-based foods like fruits, vegetables, and whole grains–which are all nutrient-rich and full of antioxidants–because they happen to contain carbs. And while someone on a keto diet will likely drop pounds in the short term, it is difficult to sustain by eating a diet high in meat, butter, and animal fat, which has been scientifically shown to increase your lifetime risk of heart disease, cancer, diabetes, and premature death from all causes. Meanwhile, a plant-based diet lowers your risk of death from all causes, recent studies have found.

In the rare case of death related to keto dieting itself, the kidneys are forced to work hard to filter and process out all the ketones, by-products of burning fat, and at times the kidneys can't keep up and go into failure. Studies show that keto diet side effects include kidney stones and other complications when the body gets overloaded with protein. (The current recommended intake for protein averages 46 grams per day for women, and 56 grams for men, according to the Harvard Medical School Newsletter.) Meanwhile too much fat in the diet can lead to fatty liver since your liver is unable to process the amount of fat being consumed. A study of a "Very Low-Calorie Keto Diet " where overweight or obese patients were given a strict diet of 500 to 800 calories a day showed little renal side effects, but the authors stressed that the subjects were put on regulated meal replacements and their food was monitored, so since their intake was kept to a low-calorie level, there was no possibility of them eating too much protein or too much fat, which can happen in real life.

The Best Way to Go Keto is On a Mostly Plant-Based Diet.

The safest way to try to achieve weight loss is on a plant-based diet, and there is a small Venn diagram of overlap between keto foods and plant-based foods. For how to achieve this, you have to look at the fat, protein and carb ratio of legumes, fruits and vegetables, such as avocados and beans, nuts and plant-based oils, explains vegan chef Suzie Gerber, who lost 50 pounds on a plant-based diet and now helps others to be healthy and learn to eat a plant-based diet too.

"You are prioritizing plant-based fats from nuts, plant-oils, and whole foods like avocados. It may take a few days of eating this way to get into ketosis, explains Gerber, since there is a "fat adaptive" period in all keto diets, where you train the body to burn fat for fuel, but you can speed this up by practicing intermittent fasting, which is not eating for up to 14 or 16 hours and then eating keto-friendly plant-based foods during the 8 to 10 on-hours, focusing on eating a plant-based diet. She suggests that you have to leave off bread, alcohol and other carbs that will put you over the limit of 5 percent of your calories a day from carbs. Dr. Jason Fung, author of Life in the Fasting Lane, told The Beet that his patients often combine Intermittent Fasting and keto diet choices for the fastest weight loss results.

The foods to eat for keto plant-based weight loss: Net carbs of 5 grams or lower

Practically speaking, Gerber explains, you have to add as many vegetables as possible to your plate to lose weight. "There are some vegetables that are high in carbs and some not so high and it's about understanding the fiber content." She explains that broccoli rabe is high in fiber and low in carbs, while broccoli is the other way around. So while it seems random, there is a list of foods that are both keto and plant-based. These are the ones you eat on repeat, she told us. Once you get the hang of it, Gerber adds, it's easy to fill up on fiber and not feel hungry.

One of the obstacles is that it can take 2 weeks on a vegan keto diet to become fat adaptive, she added. So be patient, and add in exercise, or try combining keto and plant-based eating with intermittent fasting, she recommends. And know this: "Avocado is your new best friend."

Here is the hero list of plant-based keto foods that she recommends:

  • Nuts: Pecans and walnuts are quite low in carbs. Macadamia nuts might be the best. You learn where the different choices are and focus on those.
  • Greens: Spinach and broccoli rabe are low in net carbs. And so is green pepper.  Choose green instead of yellow or orange or red peppers for the net carbs.
  • Meatless meat and non-dairy cheese replacements. If you need to get a fair amount of oils this is a way to go. It's much easier to get oil from meatless meat and non-dairy cheese than just in vegetables alone.
  • Cashew butter in a smoothie, or almond butter. Keep your protein and nut fats high.
  • Avocados are your best friend. You'll want to have avocado on everything, with every meal.

For keto-friendly foods look for vegetables with the lowest net carbs such as:

If you approach the plant-based keto diet as a finite or "micro" diet, which lasts for a month or so, and you know it's restrictive, Gerber explains, you can lose a healthy percent of your body weight and most of it as fat, and stay plant-based. When you get to the end of the time that you spend doing it, you will likely not have put the weight back on and you'll still have better muscle tone and a new baseline. She suggests cycling through shorts stints on keto rather than staying on it.

By the end of your months of cycling through keto and plant-based, then maintaining your healthy approach, you will be eating a more diverse array of foods,  "with some sanity," she adds. So when you go keto on a plant-based diet, she says, only try it in short bursts. It's still effective, but this way it's also healthy.

Gerber adds that a plant-based keto diet is easier than keto on a meat-based diet since you stay energized. "I never had 'keto flu' where you feel awful and tired all day. I never had the weird body odors or felt sick the way some people report having. Lots of water helps. Keeping really hydrated helps a lot." Drinking plenty of water is always a good idea. Before you start a strict diet of any kind, it's best to check with your doctor. Being thin is not the goal Being healthy is!