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14 Maintenance and Adherence How to Increase Maintenance • Long-term sustainability may be improved by behavioral analogies like budgeting. Expectation is not avoidance of all carbohydrates but specific choices of foods low in digestible carbohydrate. • Cravings for carbohydrate-rich foods are common, and unplanned deviations from any dietary pattern or lifestyle plan are normal and to be expected. Counseling emphasis should be placed on returning to the prescribed eating pattern and developing plans to remove, avoid or respond differently to triggers. • Discussing in plain language "binge management strategies" and "emotional management strategies" initially and periodically is essential. • Vegetarian dietary patterns, even vegan patterns, can be adapted to a low- carbohydrate goal with the inclusion of vegetable products which are high in protein content — e.g., soybeans, tofu, tempeh, and vegetable fats such as avocados, olives, nuts, seeds and nut butters. Table 5. How to Manage/Prevent Potential Side Effects Potential Negative Effects Prevention/Management Solution Transient symptoms such as headache, fatigue, lightheadedness or diarrhea, commonly called the "keto flu." If uncontrolled hypertension or heart failure is not present, adding fluid and sodium (e.g., bouillon 1–2 cubes/day) can prevent or reduce these symptoms. ese symptoms typically resolve in 7–10 days. As with viral flu, patients should rest and avoid heavy exertion during this initial stage of the nutrition plan if symptoms occur. Halitosis Increase water intake, maintain good oral hygiene and use parsley, sugarless mints or chewing gum. In some cases, modification of macronutrient intake may be helpful. Large increases in LDL If LDL cholesterol increases more markedly, this can be managed by focusing on intake of plant-based foods (non-starchy vegetable consumption), leaner protein sources and increased unsaturated fats while reducing foods high in saturated fat (e.g., full-fat dairy products like butter, cream and cheese; processed meats; poultry skin). Constipation To prevent constipation, providers should emphasize non-starchy vegetables high in insoluble fiber, adequate fluid intake with the majority as water, and regular weight-bearing physical activity. If constipation occurs, stool soeners such as docusate should be the first line choice for treatment, followed by osmotic laxatives (See Table 6). Stimulant laxatives should not be used regularly due to potential risk of bowel hypotonia and dependency. Hypoglycemia Lowering carbohydrate intake should not cause hypoglycemia unless there is concomitant use of insulin or insulin secretagogues.