Written by: Heather Cooan
Determining the relationship between Lichen Sclerosus (LS) and diet on your symptoms, flares, and condition progression can be confusing. Still, it may be one of the most helpful tools in your toolbox when it comes to finding relief and slowing or stopping your condition from advancing.
Since few scientific studies have looked at the direct impact of diet on LS, they offer little to no insight into such a broad, complex topic. And, as this article outlines, what exists in the world of scientific research on LS and diet is problematic at best.
Poorly structured research studies, small sample sizes, and lack of study replication lead to a lack of confidence in drawing accurate conclusions from the data.
But, even if there aren’t many studies specifically looking at diet concerning LS, we know that LS is a chronic inflammatory skin condition primarily affecting the anus and genitals’ skin. As such, we can better understand how diet impacts LS through research that looks at gut health, diet and inflammation, or diet and immunity. 1
Finding What You're Looking For
In this article you will find information about:
Autoimmune Dietary Approach for LS
As more research is published, a stronger argument exists to class LS as an autoimmune condition. Per a vast review published in 2019, 82% of the 532 LS patients had at least one type of autoimmune condition2, suggesting a strong, positive association between LS and autoimmunity, particularly in females.3
As a clinician, I agree with Dr. Alessio Fasano, Director of the Center for Celiac Research and Treatment at Massachusetts General Hospital, who found that three things must be present for autoimmunity to develop:
A new study from 2020 reaffirms this theory, stating, “Genetic predisposition, exposure to triggering environmental factors, and damage to intestinal wall function, secondary to poor functioning of paracellular tight junctions, appear to be crucial ingredients presented in the pathogenesis of autoimmune diseases.”4
And, the researchers don’t stop there. They acknowledge that a lifelong battle with autoimmunity isn’t a foregone conclusion for those of us with one (or more autoimmune conditions). Once you have it, you’re not powerless. Just the opposite! Autoimmunity can be moderated or even overturned completely by identifying and addressing your specific body's triggers and eating a diet that will allow you to heal and balance your gut.
What are Oxalates?
Within the LS community, you’ve likely heard a lot about high-oxalate foods and how they can aggravate symptoms.
Oxalates, or oxalic acid, are naturally occurring organic compounds present in a wide variety of plant-based foods.8
They are a plant defense mechanism used to ward off predators. Similar to lectins and phytates, and other plant defense compounds, oxalates are antinutrients that bind to minerals, like calcium or iron, and form oxalate compounds that reduce bioavailability.
How do Oxalates in your Diet Affect Lichen Sclerosus?
While there are no direct studies investigating the role oxalates play in LS9, a 1997 study on vulvodynia, a vulvar pain condition, found that 24% of participants saw positive results when following a low-oxalate diet and calcium citrate supplementation, leading researchers to determine that urinary oxalates may be an irritant for vulvar pain, though likely not the primary cause.10
One case study of a vulvodynia patient who had elevated urinary pH and oxalates showed that a year of calcium citrate treatment to reduce urinary oxalate concentrations led to them being able to resume normal work, and sexual and recreational activities without pain. When the supplement was removed, their symptoms returned — again suggesting that oxalates may play a role in vulvodynia.11
However, in a study from 2008, researchers concluded that dietary oxalate consumption doesn’t appear to be associated with a greater risk of developing vulvodynia.12
A more recent study reviewing LS treatment options from 2021 suggested that eating foods high in oxalate leads to worsening LS symptoms, but acknowledged that there is no clear association between eating a low-oxalate diet and an improvement of LS symptoms.13
In the clinic, I find that if a client has a hard time breaking down oxalates and they have LS, then consuming a diet rich in oxalates can absolutely cause flares. However, it is not the case that most LS patients have issues with breaking down oxalates.
What is Histamine?
In the clinic, I find that many LS patients who have experienced some relief from removing oxalates are really dealing with a histamine breakdown problem, not an oxalate breakdown problem, as many foods contain both.
The National Institute of Health (NIH) likes to refer to histamine as a ‘frenemy’ of the body, and that’s because it’s equal parts friend and foe.
Histamine is an essential compound in our body’s immune and digestive systems. It plays a key role as a neurotransmitter in our central nervous system.15
It’s a very complex compound when it comes to our immune systems, affecting the inflammatory process, as well as having regulatory functions in both the innate and adaptive immune responses.16
But for all the good it does, histamines are at the root of all allergies: hay fever, food allergies, and skin allergies. Since histamine is a signaling molecule, it doesn’t always get things right. As antigens, they sometimes cause overreactions in the immune system, particularly when responding to harmless substances.
In a balanced body without dysfunction, histamine is released in response to an antigen, broken down by enzymes, and removed from the body.
Allergic reactions and sensitivities to dietary histamine, also known as histamine intolerance, are inappropriate histamine responses. Histamine intolerance results from the body’s inability to metabolize ingested histamine.17 It is a non-allergic food hypersensitivity or an adverse reaction to food that doesn’t have an immunological basis.
Though there hasn’t been an investigation into histamine intolerance and LS specifically, one study found functional differences in mast cells, major producers of histamine in the body, between patients with Lichen Planus (LP) and healthy participants. LP is a skin condition similar to LS. This finding suggests a link between the neurogenic inflammatory mechanisms of histamine and inflammatory skin conditions.18
At the root of histamine intolerance is an inability or reduced ability to break down ingested histamine, which may be compounded by poor gut health, stress, hormonal imbalances, nutritional deficiencies, poor methylation in the liver, or a combination of these factors.
Let's Talk About Sugar in Your Diet and Lichen Sclerosus
You can’t talk about Lichen Sclerosus and diet without taking a look at our sweet friend sugar.19 There’s plenty of evidence showing that diets high in refined sugar and starch, that are low in fruits, vegetables, whole grains, and omega-3 fatty acids can cause an activation of the innate immune system leading to chronic inflammation.20
The Standard American Diet (SAD) and the consumption of high-sugar soft drinks often lead to an elevated blood glucose level known as hyperglycemia. And hyperglycemia is a hallmark of metabolic disorders,21 including obesity and diabetes.
When someone suffers from a metabolic disorder, they have increased levels of glucose circulating in their blood, and this sustained hyperglycemia begins the degenerative process of widespread inflammation.22 This inflammation is associated with LS, Lichen Planus, and a whole host of other chronic inflammatory conditions.23
Even in the early ‘70s, researchers were understanding the negative impacts that sugar has on our immune system. One study tested a variety of simple sugars, and found that all of them significantly reduced the ability of white blood cells to eliminate pathogens.24 As our understanding of the immune system is evolving, the harmful effects of sugar are only becoming more apparent.25
How can we reduce sugar in our LS diet?
Well, believe it or not, fruits and vegetables contain natural sugars, and when included in a balanced diet, they constitute all the carbs your body requires, and possibly surpass what’s needed. Since you meet your needs through these whole foods, anything containing added sugars will almost always result in having more than your body can handle.
Can Dairy Affect Lichen Sclerosus?
Another key component of the Standard American Diet is dairy, especially milk fats and milk solids, which are major components of processed, shelf-stable foods. Several studies demonstrate strong evidence that exposure to dietary allergens, including milk proteins, during childhood increases our overall risk of developing autoimmunity.26
There’s also growing evidence that an overlap exists between oral tolerance, food antigens, and autoimmune diseases or immune-mediated disorders.
A recent review of clinical trials that looked at changes in inflammatory markers in relation to consuming dairy products found that the inflammatory score (IS) was significantly positive for the entire data set and of those with a bovine allergy IS indicated pro-inflammatory activity.27
However, when looking at the US population-level burden of cow’s milk allergy, a study found that approximately 1 in 20 self-report a sensitivity, while less than 1 in 50 have a physician-confirmed milk protein allergy.28 When extrapolated to the entire population, 1 in 20 represents over 16 million people, so even if it’s not a physician-confirmed allergy, we’re talking about a lot of people who believe dairy is problematic for them.
If you experience digestive discomfort after eating dairy or feel that it aggravates your LS symptoms, reduce or eliminate:
Gluten and Inflammation
The most well-known or widely publicized potential food trigger is gluten. But there's a good reason that gluten has gotten such a bad rap. 2022 alone has seen at least three studies confirming the role gluten plays in producing inflammation in the gut,29 leading to celiac disease30 and other chronic inflammatory conditions, including neurodegeneration31, in genetically susceptible people.
Beyond celiac disease, gluten, or more specifically gliadin, the protein found in wheat, has been shown to cause non-celiac gluten sensitivity, activating T-cells and triggering a pro-inflammatory response associated with autoimmunity. Gluten has been shown to increase intestinal permeability, disturb the gut microbiome, increase oxidative stress and even change the expression of some genes.32
Foods to Avoid Gluten
Since a lot of evidence supports gluten’s role in inflammation, gluten is high on the list when it comes to LS foods not to eat. Eliminate all gluten-containing grains and flours, including:
Elimination Diets are Not for Everyone
While elimination diets may help you identify your trigger foods, they’re not without pitfalls.
One potential pitfall is that restrictive eating can trigger disordered eating patterns. Some susceptible people may develop orthorexia, an unhealthy obsession with healthy eating, or anorexia, an eating disorder characterized by extreme restriction, weight loss, and body dysmorphia.
It may contribute to restriction/binge cycles, an all-or-nothing mentality manifested in our relationship with food, which can be much more harmful than helpful.
Elimination diets also fail to recognize that most of us have social, emotional, and cultural connections to food. Sometimes managing such extreme restrictions cause so much overwhelm and stress that we end up worsening our symptoms, making the diet less effective as the learning tool it’s meant to be.
Since diet plays a significant role in adjusting the composition of the gut microbiome, unhealthy short- or long-term changes to dietary patterns can cause shifts to our intestinal flora that lead to decreased biodiversity, poor gut health, and unwanted metabolic shifts.36
Mediator Release Test
The shortcut I use in the clinic is food sensitivity testing, specifically, Mediator Release Testing or MRT. This blood test provides a functional measurement of diet-induced sensitivity pathways, producing a report that shows you how your body reacts to 170 different foods and additives.37
The MRT simplifies highly complex metabolic reactions. It identifies foods and food groups that are likely to be the most problematic, including many food additives, ensuring that you eliminate your likely nutritional triggers, and provides a way to retest after a period of targeted restriction.
A pitfall of MRT is that it may be difficult for some LS patients to access and can be cost-prohibitive.
Therapeutic Diets for Lichen Sclerosus
Another option on your health journey is to follow one of the evidence-based therapeutic diets. Many people, myself included, have found their way back to a balanced, healthy body by revamping their diet and giving themselves a lifestyle makeover.
The Autoimmune Protocol – AIP for LS
If you’ve ever spent time researching a diet that may help you manage your LS symptoms, you’ve surely come across the Autoimmune Protocol or AIP. An extension of the Paleo diet, the AIP diet has an initial elimination phase, where you remove known inflammatory triggers, including:
During the elimination phase, the focus of the diet is to remove anything that may be triggering intestinal inflammation, gut imbalance, or symptomatic food intolerance, while emphasizing fresh, nutrient-dense whole foods, bone broth, and lacto-ferments.38
A maintenance phase, dedicated to achieving measurable improvement in symptoms, follows the elimination phase. And once your LS symptoms have improved significantly, you will move into a reintroduction phase, pinpointing and eliminating foods that negatively impact your symptoms while adding well-tolerated foods back in.
Though most of the scientific research details success in treating inflammatory bowel disease with AIP,3940 treating inflammation in the bowel is at the heart of treating all autoimmunity, including LS. Following AIP has led to many LS success stories! Including one of the originators of AIP, Angie Alt, who detailed her journey with diet and Lichen Sclerosus for us in this interview.
The Ketogenic Diet – Keto for Lichen Sclerosus
I, and many others, can personally attest to the healing power of the ketogenic diet, another healing diet that focuses on shifting your body into an alternative metabolic pathway, ketosis, and eliminating known inflammatory triggers to initiate deep healing.
The hallmark of the therapeutic keto diet is that it’s a very low-carbohydrate, moderate-protein, and high-fat diet that induces ketosis, a metabolic state where your body derives energy from ketone bodies, rather than glucose.41 This alternative metabolic state has been linked to a reduction in systemic inflammation and increased healing potential for everything from autoimmune conditions to cancer.42
Most of our scientific understanding of how ketosis works comes from our understanding of how our body metabolizes in a fasting state, because the ketogenic diet causes our bodies to essentially mimic a fasting state.43 The longer you stay on keto, and properly in ketosis, your body will go through a series of healing stages44that balance the gut, calm inflammation and burn through excess body fat.
Working With a Functional Medicine Practitioner
One of the best things about dietary intervention is that it’s empowering! You are responsible for and highly capable of finding the answers and guiding your body back into balance and good health.
While you can certainly self-direct your healing journey from start to finish: identifying food triggers, tracking symptoms, addressing nutritional deficiencies, and seeking out knowledge and support, Functional Medicine practitioners can be useful in guiding, coaching, and supporting you through the process.
Our role is to use self-directed lab work to break the cycle of trial and error once and for all. We put in hours of research, dive into every specific health challenge, and connect the dots between your lab work, symptom history, and overall health timeline.
One of our biggest roles is to help eliminate sources of stress, including both mental and emotional stress, and hidden stressors, like infections, nutritional deficiencies, food sensitivities, heavy metals, and other environmental toxins, and then identify specific healing opportunities and restore the body to normal function.
Don’t be afraid to seek out a Functional Medicine Doctor, Functional Nutritionist, or Naturopathic Doctor to aid in systematically working towards our goal — reducing your symptoms, improving your quality of life, and supporting your body to put Lichen Sclerosus into remission or as close to it as possible.
Check out this free podcast interview which goes into more detail on how nutrition therapy can help you manage Lichen Sclerosus.
Troubleshooting Your Root Cause Contributors
In this 2022 Holistic Healing Summit session, Heather Cooan walks us through her framework for identifying the autoimmune root cause contributors to your specific condition's process and the corresponding nutrition and lifestyle changes you can make to find relief.
Heather is a Functional Nutritionist and Educator helping women suffering from autoimmunity and cancer take control of their health and care through education, data-driven nutritional therapy, and strategic lifestyle design. Learn more about Heather on her website.
- Cooan H. Digestive Dysfunction: The Long-Term Impact. HeatherCooan. Published September 17, 2020. Accessed November 20, 2022. https://heathercooan.com/digestive-dysfunction/
- Terlou A, Santegoets LA, van der Meijden WI, Heijmans-Antonissen C, Swagemakers SM, van der Spek PJ, et al. An autoimmune phenotype in vulvar lichen sclerosus and lichen planus: a Th1 response and high levels of microRNA-155. J Invest Dermatol. 2012 Mar;132(3 Pt 1):658-66. doi: 10.1038/jid.2011.369. Epub 2011 Nov 24.
- Tran DA, Tan X, Macri CJ, Goldstein AT, Fu SW. Lichen Sclerosus: An autoimmunopathogenic and genomic enigma with emerging genetic and immune targets. Int J Biol Sci. 2019 Jun 2;15(7):1429-1439. doi: 10.7150/ijbs.34613
- Paray BA, Albeshr MF, Jan AT, Rather IA. Leaky Gut and Autoimmunity: An Intricate Balance in Individuals Health and the Diseased State. Int J Mol Sci. 2020 Dec 21;21(24):9770. doi: 10.3390/ijms21249770
- Vieira-Baptista P, Lima-Silva J, Cavaco-Gomes J, Beires J, Martinez-de-Oliveira J. What differentiates symptomatic from asymptomatic women with lichen sclerosus? Gynecol Obstet Invest. 2015;79(4):263-8. doi: 10.1159/000367788
- Cooan H. Autoimmune Triggers Worksheet. HeatherCooan. Accessed November 8, 2022. https://heathercooan.com/lspodcast/
- Cooan H, ONC HC MBA, NTP, FDN-P. Food Sensitivity, Intolerance or Allergy? HeatherCooan. Published January 2023. https://heathercooan.com/the-six-stages-of-ketosis/
- Cooan H, ONC HC MBA, NTP, FDN-P. Oxalates Guide: What Are They, Why Should I Care? HeatherCooan. Published September 3, 2020. https://heathercooan.com/oxalates/
- Cooan H, ONC HC MBA, NTP, FDN-P. Oxalates and Vulvar Pain. HeatherCooan. Published September 30, 2022. https://heathercooan.com/oxalates-and-vulvar-pain/
- Baggish MS, Sze EH, Johnson R. Urinary oxalate excretion and its role in vulvar pain syndrome. Am J Obstet Gynecol. 1997 Sep;177(3):507-11. doi: 10.1016/s0002-9378(97)70137-6
- Solomons CC, Melmed MH, Heitler SM. Calcium citrate for vulvar vestibulitis. A case report. J Reprod Med. 1991 Dec;36(12):879-82.
- Harlow BL, Abenhaim HA, Vitonis AF, Harnack L. Influence of dietary oxalates on the risk of adult-onset vulvodynia. J Reprod Med. 2008 Mar;53(3):171-8.
- Singh N, Mishra N, Ghatage P. Treatment Options in Vulvar Lichen Sclerosus: A Scoping Review. Cureus. 2021 Feb 24;13(2):e13527. doi: 10.7759/cureus.13527
- Chai W, Liebman M. Effect of different cooking methods on vegetable oxalate content. J Agric Food Chem. 2005 Apr 20;53(8):3027-30. doi: 10.1021/jf048128d
- Cooan H, ONC HC MBA, NTP, FDN-P. Histamine Intolerance an Overview. HeatherCooan. Published January 12, 2023. https://heathercooan.com/histamine-intolerance-an-overview/
- Branco ACCC, Yoshikawa FSY, Pietrobon AJ, Sato MN. Role of Histamine in Modulating the Immune Response and Inflammation. Mediators Inflamm. 2018 Aug 27;2018:9524075. doi: 10.1155/2018/9524075
- Comas-Basté O, Sánchez-Pérez S, Veciana-Nogués MT, Latorre-Moratalla M, Vidal-Carou MDC. Histamine Intolerance: The Current State of the Art. Biomolecules. 2020;10(8):1181. doi: 10.3390/biom10081181
- Zalewska A, Brzezińska-Błaszczyk E, Omulecki A, Pietrzak A. Functional studies of skin mast cells in lichen planus. Arch Dermatol Res. 1997 Apr;289(5):261-4. doi: 10.1007/s004030050190
- Cooan H, ONC HC MBA, NTP, FDN-P. How Sugar Drives Inflammation. HeatherCooan. Published November 21, 2022. https://heathercooan.com/sugar-drives-inflammation/
- Giugliano D, Ceriello A, Esposito K. The effects of diet on inflammation: emphasis on the metabolic syndrome. J Am Coll Cardiol. 2006 Aug 15;48(4):677-85. doi: 10.1016/j.jacc.2006.03.052
- Hert KA, Fisk PS 2nd, Rhee YS, Brunt AR. Decreased consumption of sugar-sweetened beverages improved selected biomarkers of chronic disease risk among US adults: 1999 to 2010. Nutr Res. 2014 Jan;34(1):58-65. doi: 10.1016/j.nutres.2013.10.005. Epub 2013 Oct 16.
- Della Corte KW, Perrar I, Penczynski KJ, Schwingshackl L, Herder C, Buyken AE. Effect of Dietary Sugar Intake on Biomarkers of Subclinical Inflammation: A Systematic Review and Meta-Analysis of Intervention Studies, Nutrients. 2018;10(5):606. doi: 10.3390/nu10050606
- Hashba H, Bifi J, Thyvalappil A, Sridharan R, Sreenivasan A, Mathew P. Prevalence of Metabolic Syndrome in Patients with Lichen Planus: A Cross-sectional Study from a Tertiary Care Center. Indian Dermatol Online J. 2018 Sep-Oct;9(5):304-308. doi: 10.4103/idoj.IDOJ_27_18
- Sanchez A, Reeser J, Lau H, Yahiku P, Willard R, McMillan P, et al. Role of sugars in human neutrophilic phagocytosis. Am J Clin Nutr. 1973;26:1180-4. doi: 10.1093/ajcn/26.11.1180
- Cooan H, ONC HC MBA, NTP, FDN-P. The Effects of Sugar on The Immune System. HeatherCooan. Published April 18, 2020. https://heathercooan.com/effects-of-sugar-on-the-immune-system/
- Vieira Borba V, Lerner A, Matthias T, Shoenfeld Y. Bovine Milk Proteins as a Trigger for Autoimmune Diseases: Myth or Reality? Int J Celiac Dis. 2020;8(1):10-21. doi: 10.12691/ijcd-8-1-3
- Bordoni A, Danesi F, Dardevet D, Dupont D, Fernandez AS, Gille D, et al. Dairy products and inflammation: A review of the clinical evidence. Crit Rev Food Sci Nutr. 2017 Aug 13;57(12):2497-2525. doi: 10.1080/10408398.2014.967385
- Warren CM, Agrawal A, Gandhi D, Gupta RS. The US population-level burden of cow's milk allergy. World Allergy Organ J. 2022 Apr 21;15(4):100644. doi: 10.1016/j.waojou.2022.100644
- Auricchio R, Calabrese I, Galatola M, et al. Gluten consumption and inflammation affect the development of celiac disease in at-risk children. Sci Rep. 2022;12:5396. doi: 10.1038/s41598-022-09232-7
- 23. Barone MV, Auricchio R, Nanayakkara M, Greco L, Troncone R, Auricchio S. Pivotal Role of Inflammation in Celiac Disease. Int J Mol Sci. 2022; 23(13):7177. doi: 10.3390/ijms23137177
- Philip A, White ND. Gluten, Inflammation, and Neurodegeneration. Am J Lifestyle Med. 2022 Jan 11;16(1):32-35. doi: 10.1177/15598276211049345
- Lerner A, Shoenfeld Y, Matthias T. Adverse effects of gluten ingestion and advantages of gluten withdrawal in nonceliac autoimmune disease. Nutr Rev. 2017 Dec 1;75(12):1046-1058. doi: 10.1093/nutrit/nux054
- Jacobs L, Gilliam A, Khavari N, Bass D. Association between lichen sclerosus and celiac disease: a report of three pediatric cases. Pediatr Dermatol. 2014 Nov-Dec;31(6):e128-31. doi: 10.1111/pde.12402. Epub 2014 Nov 10.
- Karadag AS, Kavala M, Ozlu E, Zindancı İ, Ozkanlı S, Turkoglu Z, et al. The co-occurrence of lichen sclerosus et atrophicus and celiac disease. Indian Dermatol Online J. 2014 Dec;5(Suppl 2):S106-8. doi: 10.4103/2229-5178.146172
- Cooan H, ONC HC MBA, NTP, FDN-P. Managing Inflammation Through Diet. HeatherCooan. Published June 3, 2019. https://heathercooan.com/managing-inflammation-through-diet/
- Adithya KK, Rajeev R, Selvin J, Kiran GS. Dietary Influence on the Dynamics of the Human Gut Microbiome: Prospective Implications in Interventional Therapies. ACS Food Sci & Tech. 2021; 1(5):717-736. doi: 10.1021/acsfoodscitech.0c00075
- The Patented Mediator Release Test (MRT®). Oxford Biomedical Technologies, Inc. https://www.nowleap.com/the-patented-mediator-release-test/
- Konijeti GG, Kim N, Lewis JD, Groven S, Chandrasekaran A, Grandhe S, et al. Efficacy of the Autoimmune Protocol Diet for Inflammatory Bowel Disease. Inflamm Bowel Dis. 2017 Nov;23(11):2054-2060. doi: 10.1097/MIB.0000000000001221
- Chandrasekaran A, Groven S, Lewis JD, Levy SS, Diamant C, Singh E, et al. An Autoimmune Protocol Diet Improves Patient-Reported Quality of Life in Inflammatory Bowel Disease. Crohns Colitis 360. 2019 Oct;1(3):otz019. doi: 10.1093/crocol/otz019. Epub 2019 Aug 7.
- Chandrasekaran A, MD, Molparia B, PhD, Akhtar E, MD, Wang X, MS, Lewis JD, MD, Chang JT, MD, et al. The Autoimmune Protocol Diet Modifies Intestinal RNA Expression in Inflammatory Bowel Disease, Crohn's & Colitis October 2019;1(3):360. doi: 10.1093/crocol/otz016
- Cooan H, ONC HC MBA, NTP, FDN-P. Nutritional vs. Therapeutic Ketosis. HeatherCooan. Published November 6, 2022. https://heathercooan.com/therapeutic-ketosis/
- Dowis K, Banga S. The Potential Health Benefits of the Ketogenic Diet: A Narrative Review. Nutrients. 2021 May 13;13(5):1654. doi: 10.3390/nu13051654.
- Zhu H, Bi D, Zhang Y, Kong C, Du J, Wu X, et al. Ketogenic diet for human diseases: the underlying mechanisms and potential for clinical implementations. Signal Transduct Target Ther. 2022 Jan 17;7(1):11. doi: 10.1038/s41392-021-00831-w
- Cooan H, ONC HC MBA, NTP, FDN-P. The Stages of Ketosis. HeatherCooan. Published January 11, 2023. https://heathercooan.com/the-six-stages-of-ketosis/