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Before you start: tests, medicines and who should wait

The lab tests worth doing first, the medicines that make low-carb and fasting risky, and the side effects to expect.

Compiled by Jayakanthan, Richmond, Virginia

Last reviewed against sources: October 25, 2026

On this page
  1. 1First: check your medicines
  2. 2Who should not start without a specialist
  3. 3The lab panel
  4. 4Side effects to expect
  5. 5Sun and vitamin D in Virginia
  6. 6Amla, flaxseed and omega-3
For my family only

This site is curated for my own family members. It is not a recommendation or a diet plan for anyone else. Do not change your diet, start fasting, or change any medicine without your own doctor's advice. We are not responsible for any consequences of following this information without proper medical supervision.

Read this first: This page is education, not a treatment plan. If you take insulin, a sulfonylurea (glipizide, glimepiride, gliclazide), an SGLT2 inhibitor (Jardiance, Farxiga, Invokana), blood pressure pills, warfarin or lithium, or if you are pregnant, breastfeeding, under 18, have kidney disease or a history of an eating disorder, do not start a low-carb diet or fasting without your doctor.

The Tamil Paleo chart was right about one thing most diet advice skips: get tested before you start. No trial shows that testing itself improves outcomes D, but the safety logic is strong. A baseline tells you whether your plan is working, and lets your doctor catch the people for whom it is risky. This page updates the chart's list of 11 tests and adds the medicine checks it left out.

1First: check your medicines#

This matters more than any lab test. Cutting carbohydrates lowers blood sugar and blood pressure within days, often faster than your doctor expects. Medicines dosed for your old diet can then push you too low.

If you takeRisk on low-carb or fastingWhat to do
InsulinLow blood sugar (hypoglycaemia)Doses usually need to come down before or as you start. A UK practical guide for GPs suggests about a 50% initial cut, bolus (mealtime) insulin first, under supervision D[1]. Never stop insulin on your own.
Sulfonylureas: glipizide, glimepiride, gliclazide, glyburide (glibenclamide); also repaglinideLow blood sugarThe same guide suggests reducing or stopping these at the start, by your doctor D[1]. Fasting days doubled hypoglycaemia in a trial even with dose cuts B[2].
SGLT2 inhibitors: Jardiance (empagliflozin), Farxiga (dapagliflozin), Invokana (canagliflozin), Steglatro (ertugliflozin), and combination pills such as Synjardy, Xigduo, Glyxambi, Invokamet, Trijardy, QternKetoacidosis with normal-looking sugar (euglycaemic DKA)Case reports describe ketoacidosis within days of starting keto while on these drugs C[3,4]. The UK guide suggests stopping them when a low-carb diet starts [1]. Never stop them yourself: many people take Farxiga or Jardiance for heart failure or kidney protection, not just diabetes. In that case the safer change may be to skip keto and long fasts. Ask your prescriber before you begin.
GLP-1 and related drugs: Ozempic, Wegovy, Rybelsus (semaglutide), Mounjaro, Zepbound (tirzepatide), TrulicityAlready lower appetite; adding fasting or very low intake risks dehydration, muscle loss and, if combined with insulin or a sulfonylurea, low sugarTell your prescriber before adding fasting. Keep protein up and add strength training D.
Blood pressure pills, especially diuretics (water pills)Dizziness, low blood pressure, dehydrationCheck home blood pressure daily for the first weeks and share it with your doctor D.
WarfarinINR swings when your intake of greens (vitamin K) changesKeep the weekly amount of keerai steady and tell your anticoagulation clinic before changing your diet C[5].
LithiumHigher lithium levels with early fluid loss and fastingOnly with your psychiatrist involved D[6].
MetforminLow risk of hypoglycaemia on its own; long-term use lowers B12Usually continued. Get B12 checked B[7].
Go to the emergency room if

you are on an SGLT2 inhibitor and have nausea, vomiting, belly pain or fast, deep breathing, even if your glucose meter reads normal. Ask for a ketone test.

2Who should not start without a specialist#

  • Pregnancy, trying to conceive, or breastfeeding. The chart claims "protection from gestational diabetes". The evidence leans the other way: in a large US cohort, women whose eating pattern before pregnancy was low in carbohydrate had about 27% more gestational diabetes, and the risk came from the animal-fat-and-protein version of that pattern C[8]. Low carbohydrate intake around conception was linked to about 30% higher odds of neural tube defects, probably because fortified grains supply folic acid C[9]. Ketoacidosis has been reported in breastfeeding women on low-carb diets (case reports) C[10]. The US recommended minimum in pregnancy is 175 g of carbohydrate a day [11].
  • Type 1 diabetes or LADA: very low carb raises the risk of hypoglycaemia and DKA C[12]. Only with your diabetes team.
  • Kidney disease (eGFR under 60): international kidney guidelines advise about 0.8 g protein per kg per day in CKD stages 3 to 5, and avoiding more than 1.3 g/kg in anyone at risk of progression C[13]. High-meat Paleo menus easily exceed this.
  • Very high LDL (190 mg/dL or more), familial hypercholesterolaemia, high Lp(a), or known heart disease: low-carb raises LDL on average and sometimes a lot B[14,15].
  • Gout with recent flares: ketones compete with uric acid in the kidney, so flares are more likely in the first weeks C[16].
  • Kidney stones: about 1 in 17 people on long-term keto developed stones in studies that were mostly of children on epilepsy keto; about half were uric acid stones C[17].
  • Gallbladder disease or past pancreatitis: rapid weight loss raises gallstone risk C[18], and very fatty meals can trigger attacks D.
  • Under 18, or anyone with a current or past eating disorder C[19].

3The lab panel#

Ask your doctor for these at baseline. Most are routine and covered by insurance as part of a physical or diabetes screening. Track your numbers in the lab tracker.

Blood sugar

TestNormalPrediabetesDiabetes
HbA1c (3-month average)under 5.7%5.7 to 6.4%6.5% or higher
Fasting glucose (8 hours, no calories)under 100 mg/dL100 to 125 mg/dL126 mg/dL or higher
2-hour glucose after a 75 g glucose drink (OGTT)under 140 mg/dL140 to 199 mg/dL200 mg/dL or higher

Cut points from the American Diabetes Association Standards of Care 2026[20]. The ADA recommends testing all adults from age 35 and every 3 years if normal, and screening Asian Americans at a lower BMI (23 instead of 25) because diabetes appears at lower weights in Asians[21]. A "post-prandial" test after your usual lunch is not the same as a standard OGTT; use HbA1c and fasting glucose to track progress. HbA1c reads falsely high or low with anaemia and some haemoglobin variants, so it is checked together with a blood count.

Heart and cholesterol

TestWhy on this dietWhat to look for
Lipid profile (LDL, HDL, triglycerides, non-HDL)Low-carb usually drops triglycerides and raises HDL, but raises LDL on average B[14]Compare with your baseline at about 3 months. A big LDL jump needs a conversation, not a shrug.
ApoB (add)Counts the particles that build plaque. More reliable than LDL when triglycerides are low and HDL is high, the typical low-carb pattern[22]In a study of South Indian adults on a Paleo diet, ApoB rose in about 6 of 10 people[23]
Lp(a) (add, once in your life)Genetic, not changed by diet. If high, any LDL rise matters more[24,25]Under 75 nmol/L (30 mg/dL) low; 125 nmol/L (50 mg/dL) or more is high. About 1 in 5 people are high.
hs-CRPInflammation marker; a heart-risk enhancerUnder 1 mg/L lower risk, 1 to 3 average, over 3 higher

US cholesterol guidelines list South Asian ancestry itself as a risk-enhancing factor[26]. An American Heart Association statement found that most of the excess heart disease in South Asians is explained by ordinary risk factors, especially insulin resistance B[27]. That is good news: the usual levers (blood sugar, LDL, blood pressure, activity) work for us too.

Kidney, liver and the rest

TestWhy
Creatinine and eGFR, plus urine albumin-to-creatinine ratio (add)Higher protein intake and stone risk; many drugs are dosed by kidney function. Normal is eGFR 60 or more and ACR under 30 mg/g.[13]
Liver panel (ALT, AST)Baseline for fatty liver. A healthy ALT is roughly 29 to 33 U/L in men and 19 to 25 U/L in women, lower than many lab "normal" ranges[28].
Complete blood count / haemoglobinAnaemia distorts HbA1c and is common in vegetarian women.
Vitamin B12 (add)Indian vegetarians had about 4 times the risk of low B12 in one study[29], and metformin lowers it further[7].
Ferritin (add for women and vegetarians)Iron stores.
Uric acidBaseline if you have had gout or stones.
Electrolytes (sodium, potassium, magnesium) (add)Early fluid loss on low-carb, especially if you take diuretics.
TSHLow-carb can lower T3 while TSH stays normal[30]. That is not thyroid disease and it is not a thyroid "cure"; judge by TSH with your doctor.

Two tests from the chart to rethink

BVitamin D: the Endocrine Society now advises against routine testing in healthy adults.

Its 2024 guideline suggests not testing 25-OH vitamin D routinely, including in people with darker skin or obesity, and sets no target level. It suggests standard-dose supplements for adults over 75, pregnant women, and people with high-risk prediabetes[31]. Test if your doctor has a reason to, not to chase a number. See sun and vitamin D below.

DFasting insulin / HOMA-IR

Popular in low-carb circles, but there is no standard cut point, assays differ between labs, and one fasting sample is noisy[32]. Useful in research, weak for an individual. HbA1c, fasting glucose, triglycerides and waist size tell you most of the same story.

When to retest

No guideline sets a schedule for low-carb diets, so this is expert practice D: baseline, about 3 months after starting, then every 6 to 12 months. Retest sooner if your doctor changes your medicines. People on insulin or sulfonylureas should check their own glucose daily at first.

4Side effects to expect#

EffectHow common, how longWhat helps
"Keto flu": headache, tiredness, dizziness, brain fogFirst 1 to 2 weeks, usually gone by week 4 C[33]Water, and a little extra salt (rasam, neer mor) unless you have heart, kidney or blood pressure limits
ConstipationThe most commonly reported complaint C[34]More vegetables and keerai, flaxseed or chia, water
LDL riseCommon on average; large in some lean people B[14,15]Retest at 3 months; swap some ghee and coconut oil for olive or gingelly oil, nuts and fish
Kidney stonesAbout 6% over several years, mostly in children on epilepsy keto C[17]Fluids; lemon; tell your doctor about any stone history
Gout flareEarly weeks CFluids; talk to your doctor before starting if you have gout
Hair sheddingSometimes 2 to 4 months after rapid weight loss DUsually temporary; slower weight loss and enough protein

5Sun and vitamin D in Virginia#

DThe chart: "20 minutes of sun daily with 40% of the body exposed."

Right idea, wrong as a fixed rule here

  • Skin makes vitamin D only from midday UVB. In Boston (42°N) a classic study found no vitamin D production from November through February; at 34°N some production continued all winter[35]. Richmond sits at about 37.5°N, so expect little to none from roughly November to February C.
  • Darker skin needed about six times the UV dose to raise vitamin D in a small foundational study C[36]. Many people with South Asian skin may need longer than 20 minutes in summer.
  • The DMinder app estimates vitamin D from UV index and skin type but has no published validation D. Fine as a reminder of when the sun is strong; not a dose meter.

Practical: midday sun in late spring and summer, without burning; eggs, oily fish and fortified milk; and a standard-dose supplement if your doctor agrees, especially in winter, after 75, or in pregnancy[31]. Do not take mega-doses.

6Amla, flaxseed and omega-3#

C"1 amla a day raises HDL."

Small, short trials of standardized amla extract capsules (3 to 12 weeks) show better lipids, including higher HDL[37,38]. The largest single trial was supported by the extract's manufacturer. These tested extracts, not one fresh fruit, and not vitamin C as such. There is no data on heart attacks. Eat amla because it is a good fruit; do not count on it to fix your HDL.

BFlaxseed lowers blood pressure a little.

Across 33 trials, flaxseed lowered blood pressure by about 3/2.6 mmHg[39]. A Canadian trial using 30 g of ground flax a day found a larger effect in people with artery disease[40]. Use ground, not whole, seeds.

BFlax is not a substitute for fish oil.

The body converts only about 5% of flax's omega-3 (ALA) into EPA and under 0.5% into DHA[41]. Vegetarians who want EPA and DHA can use algae-based (algal) oil, which raised blood DHA as well as cooked salmon did in one study[42].

Sources on this page

Every source below was checked against its PubMed, DOI or publisher page. Grades and how we use them: evidence grades.

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  2. Corley BT, Carroll RW, Hall RM, et al. (2018). Intermittent fasting in Type 2 diabetes mellitus and the risk of hypoglycaemia: a randomized controlled trial.. Diabet Med 35(5):588-594. PMID 29405359 · doi:10.1111/dme.13595 - RCT, fasting days doubled hypoglycaemia (RR 2.05) despite dose reduction
  3. Somagutta MKR, Uday U, Shama N, et al. (2022). Dietary Changes Leading to Euglycemic Diabetic Ketoacidosis in Sodium-Glucose Cotransporter-2 Inhibitor Users: A Challenge for Primary Care Physicians?. Korean J Fam Med 43(6):361-366. PMID 36444120 · doi:10.4082/kjfm.22.0003 - Review of 14 patients with euglycaemic DKA on SGLT2 inhibitors plus keto
  4. Somagutta MR, Agadi K, Hange N, et al. (2021). Euglycemic Diabetic Ketoacidosis and Sodium-Glucose Cotransporter-2 Inhibitors: A Focused Review of Pathophysiology, Risk Factors, and Triggers.. Cureus 13(3):e13665. PMID 33824816 · doi:10.7759/cureus.13665 - Review of euglycaemic DKA with SGLT2 inhibitors; fasting and ketogenic diets as triggers
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  9. Desrosiers TA, Siega-Riz AM, Mosley BS, et al. (2018). Low carbohydrate diets may increase risk of neural tube defects.. Birth Defects Res 110(11):901-909. PMID 29368448 · doi:10.1002/bdr2.1198 - Case-control, National Birth Defects Prevention Study
  10. Marzban S, Arbee M, Vorajee N, et al. (2020). Non-diabetic ketoacidosis associated with a low carbohydrate, high fat diet in a postpartum lactating female.. Oxf Med Case Reports 2020(8):omz026. PMID 32793371 · doi:10.1093/omcr/omz026 - Case report
  11. Sweeting A, et al. (2021). The Carbohydrate Threshold in Pregnancy and Gestational Diabetes: How Low Can We Go?. Nutrients 13(8):2599. doi:10.3390/nu13082599 - Review; IOM 175 g/day minimum
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  15. Norwitz NG, Feldman D, Soto-Mota A, et al. (2022). Elevated LDL Cholesterol with a Carbohydrate-Restricted Diet: Evidence for a “Lean Mass Hyper-Responder” Phenotype.. Curr Dev Nutr 6(1):nzab144. PMID 35106434 · doi:10.1093/cdn/nzab144 - Self-selected survey of low-carb followers
  16. Goldfinger S, Klinenberg E Jr, Seegmiller JE (1965). RENAL RETENTION OF URIC ACID INDUCED BY INFUSION OF BETA-HYDROXYBUTYRATE AND ACETOACETATE.. N Engl J Med 272:351-355. PMID 14239117 · doi:10.1056/NEJM196502182720705 - Physiology study, ketones and urate excretion (no abstract on PubMed)
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  20. American Diabetes Association Professional Practice Committee for Diabetes (2026). 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2026.. Diabetes Care 49(Supplement_1):S27-S49. PMID 41358893 · doi:10.2337/dc26-S002 - ADA Standards of Care 2026, Section 2
  21. Hsia DS, Larrivee S, Cefalu WT, et al. (2015). Impact of Lowering BMI Cut Points as Recommended in the Revised American Diabetes Association's Standards of Medical Care in Diabetes-2015 on Diabetes Screening in Asian Americans.. Diabetes Care 38(11):2166-2168. PMID 26324330 · doi:10.2337/dc15-0299 - Basis for screening Asian Americans at BMI 23
  22. Soffer DE, Marston NA, Maki KC, et al. (2024). Role of apolipoprotein B in the clinical management of cardiovascular risk in adults: An Expert Clinical Consensus from the National Lipid Association.. J Clin Lipidol 18(5):e647-e663. PMID 39256087 · doi:10.1016/j.jacl.2024.08.013 - National Lipid Association expert consensus
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  27. Volgman AS, Palaniappan LS, Aggarwal NT, et al. (2018). Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association.. Circulation 138(1):e1-e34. PMID 29794080 · doi:10.1161/CIR.0000000000000580 - AHA scientific statement
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  35. Webb AR, Kline L, Holick MF (1988). Influence of season and latitude on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin.. J Clin Endocrinol Metab 67(2):373-378. PMID 2839537 · doi:10.1210/jcem-67-2-373 - Measurement study by latitude and season
  36. Clemens TL, Adams JS, Henderson SL, et al. (1982). Increased skin pigment reduces the capacity of skin to synthesise vitamin D3.. Lancet 1(8263):74-76. PMID 6119494 · doi:10.1016/s0140-6736(82)90214-8 - Small physiology study, n=5
  37. Setayesh L, Haghighat N, Rasaei N, et al. (2023). The impact of Emblica Officinalis (Amla) on lipid profile, glucose, and C-reactive protein: A systematic review and meta-analysis of randomized controlled trials.. Diabetes Metab Syndr 17(3):102729. PMID 36934568 · doi:10.1016/j.dsx.2023.102729 - Meta-analysis, 5 RCTs, 3 to 12 weeks
  38. Usharani P, Merugu PL, Nutalapati C (2019). Evaluation of the effects of a standardized aqueous extract of Phyllanthus emblica fruits on endothelial dysfunction, oxidative stress, systemic inflammation and lipid profile in subjects with metabolic syndrome: a randomised, double blind, placebo controlled clinical study.. BMC Complement Altern Med 19(1):97. PMID 31060549 · doi:10.1186/s12906-019-2509-5 - RCT, n=59, 12 weeks; extract maker supplied product
  39. Li L, Li H, Gao Y, et al. (2023). Effect of flaxseed supplementation on blood pressure: a systematic review, and dose-response meta-analysis of randomized clinical trials.. Food Funct 14(2):675-690. PMID 36622248 · doi:10.1039/d2fo02566c - Meta-analysis, 33 trials
  40. Rodriguez-Leyva D, Weighell W, Edel AL, et al. (2013). Potent antihypertensive action of dietary flaxseed in hypertensive patients.. Hypertension 62(6):1081-1089. PMID 24126178 · doi:10.1161/HYPERTENSIONAHA.113.02094 - RCT, n=110, 6 months
  41. Plourde M, Cunnane SC (2007). Extremely limited synthesis of long chain polyunsaturates in adults: implications for their dietary essentiality and use as supplements.. Appl Physiol Nutr Metab 32(4):619-634. PMID 17622276 · doi:10.1139/H07-034 - Review of ALA conversion
  42. Arterburn LM, Oken HA, Bailey Hall E, et al. (2008). Algal-oil capsules and cooked salmon: nutritionally equivalent sources of docosahexaenoic acid.. J Am Diet Assoc 108(7):1204-1209. PMID 18589030 · doi:10.1016/j.jada.2008.04.020 - Bioequivalence study; authors linked to algal oil maker per literature