Editorial: Keto Diet – A physician’s point of view.

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Should I try a ketogenic diet? 

Ketogenic low carbs diet.

Ketogenic low carb diet.

I am a scientist by trade, and I try not to dismiss a question without reading up on the research behind it.,  Recently, many of my patients have been asking the same question about ketogenic diets.  In fact, the most recent patient who asked me was a senior noncommissioned officer or NCO.  He is a very knowledgeable and intelligent man and was wit’s end and read about the diet on the internet and wanted to know more.  To him, we had found a possible miracle cure that may cure the weight gain he had acquired while working, in his new sedentary lifestyle caused by his less active job.  

His question contained two parts: “Does it work?” and “Is it safe?”  I’ve posted article not to bring attention to the diet but to show my response and what I found when I researched it for this patient.  So, I studied it, and now I want to give the doctor’s point of view on a ket or ketogenic diet.  You will quickly see why it’s hard for medical professionals to recommend keto diets even though there may be limited evidence to show that it is terrible for you and there is plenty of evidence to show that they work.  

Low Carb Breakfast

Low Carb Breakfast

Despite the recent hype, a ketogenic diet is not new. Ketogenic diets have been around for over 100-years.  They have been recommended for epilepsy since the 1970s but predate even this treatment.  They are not much different than the low carbohydrate diets we all no from the Adkin’s diets.  The low carb diet of the ketogenic diet differ from Akin’s diets by being higher in fat and lower in protein, but the philosophy is the same.  The goal is to induce ketosis and reduce hunger.   Both began with a very strict ketogenic phase, and both are considered fad diets by many medical professionals.  

What is a ketogenic diet?

As I mentioned above, the end goal of a ketogenic diet is to cause your body to release ketones into the bloodstream.  In this type of diet, we reduce our sugar intake and force our cells to use fats for energy.  Our cells prefer to use blood sugar for energy.  If we lower our carbohydrate intake, we quickly deplete our blood sugar and glycogen stores (small sugar storage capability in our liver and muscle).  To continue to function, we begin releasing stored fat molecules and converting them into ketones.  This process is called ketosis.  Most of our cells can use ketone bodies to generate energy.   Although the rest require carbohydrates, our cells can produce enough for them to function.  To obtain a ketotic state, a dieter has to reach less than 20 or 50 grams of carbohydrates.  Each person must identify their own level.  The individualization is why most dieters require the use of ketone test strips.  

Ketogenic Diet - Macronutrient Distribution

Ketogenic Diet – Macronutrient Distribution

Ketogenic diets are very low in carbohydrates.  For many, the low carbohydrates may be difficult to tolerate, but for others, it is the easiest diet to follow.  I have found that a diet rich in butter, cheese, eggs, fish, meats, nuts, sausages, and non-carbohydrate vegetables.  Basically, the ketogenic diet is high in fat with 80% of your calories, low in carbohydrates with less than 5% of your calories, and moderate in protein with 15-20% of your calories.  I have found the fat-rich diet to be very fulfilling and satiating.  The only thing that I have found to be a challenge for me is getting enough fiber.  If you do not eat enough vegetables, you will become constipated.   

These kinds of restrictive diets tend to make nutrition professionals like dietitians cringe, but I’m going to continue to give it an unbiased medical opinion.  In all honesty, the restrictive nature of the diet may make the diet difficult to follow for many Americans. It is absolutely one of the most difficult diets to maintain for the long haul.  Carbohydrates are normally at least 50% of the typical American diet.  For the carbohydrate lovers, this diet will be torture.  

What foods are allowed?  

Below is a list of the foods allowed in the diet.  

Fats allowed:  
  • animal fat
  • bacon 
  • cheese
  • coconut milk
  • eggs (yolks)
  • lard 
  • mayonnaise
  • nut oils
  • olive oil 
  • avocado and avocado oil
  • butter/Ghee
  • coconut butter
  • coconut oil
  • fatty fish
  • macadamia/other nuts
  • MCT Oil
  • nut butter
  • vegetable oil

 

Proteins such as:
  • bacon
  • chicken
  • crab
  • eggs
  • goat
  • lobster 
  • nut butter
  • pork
  • scallops
  • beef
  • clams
  • duck
  • fish
  • lamb
  • mussels
  • oysters
  • sausage
  • turkey

 

Low-carbohydrate vegetables allowed in small amounts include:
  • avocado
  • broccoli
  • cabbage
  • celery 
  • eggplant 
  • green beans
  • lettuce
  • pumpkin
  • snow peas
  • tomatoes
  • asparagus
  • Brussels sprouts
  • cauliflower
  • cucumbers
  • fennel
  • kale
  • peppers
  • radishes
  • squash
  • zucchini

Are there any weight loss benefits of a ketogenic diet?

Urine test strips

Urine test strips

Ketogenic diets are not a traditional ‘calorie counting’ diet, and you do have to keep a close count of your calories, but you do have to watch your carbohydrate intake.  Some of the diets recommend levels as low as 5 grams of carbohydrates per day, and others use that number per meal.  Some recommend less than 50 grams per day.  The bonus is that you get subtract the fiber content because that is not usable carbohydrates.  If you think that it is easy to stick to 50 grams per day, remember that most Americans eat 100-200 gram per day.  

For most people, between 20g to 50g of net carbs will result in a state of ketosis.  There is evidence that a ketogenic diet reduces seizures in children and research has shown it can be effective as medication in those that have seizures refractory to medications[1],[2],[3]. Because of these neuroprotective effects, some have pointed to Parkinson’s, Alzheimer’s, multiple sclerosis, sleep disorders, autism, and even some brain cancers[4].  However, to this date, there are no human studies to support recommending ketosis to treat these conditions.  I would not recommend using it for anything other than weight loss and seizures in pediatric patients with a physician’s advice.  

Weight loss is the primary reason patients seek to use a ketogenic diet.  Research shows good evidence of a faster weight loss when patients go on a ketogenic or very low carbohydrate diet when compared to participants on a traditional low-fat diet, or even a Mediterranean diet. As with all diets, weight regain occurs over time unless you maintain a lower calorie diet.  One study shows the beneficial effects of a long-term ketogenic diet[5].  The Ketogenic diet significantly reduced the body weight and body mass index of the patients.  Most importantly, eating a ketogenic diet did not produce any significant side effects in the patients.  This study confirms that it is safe to use a ketogenic diet for a more extended period than previously tested.  Other studies have confirmed these results[6],[7].    

Low Carbohydrate

Low Carbohydrate

Additionally, it would appear based on multiple studies that ketogenic diets reduce metabolic syndrome effects.  A ketogenic diet has been shown to improve blood sugar control for patients with type 2 diabetes[8].  This is important because insulin resistance is commonly thought to be one cause of central obesity.  A 2005 study confirmed that ketogenic diets help improve insulin sensativity[9] so they should help reduce metabolic syndrome and obesity.  

A few relevant observations on my research:

  1. Any diet type resulting in reduced energy intake will result in weight loss.
  2. Ketogenic diets are not much different than the old Adkin’s diet.  
  3. Short-term ketogenic diet studies show more favorable and less undesirable side-effects.
  4. Sustained adherence to a ketogenic diet appears to be difficult.
  5. There is lack of data supporting long-term efficacy, safety and health benefits of ketogenic diets.
  6. Lifestyle intervention in people at high risk of developing type 2 diabetes is generally seen as safe.
  7. All dieters regain the weight if they do not make a lifelong change and sustain or maintain the loss.  

The bottom line:  A ketogenic diet can accelerate weight loss. They may be difficult for may to follow because they are very restrictive, but if you can tolerate them, there is no reason to believe they are not safe and effective for weight loss.  We also do not know much about its long-term effects.  For most people trying to slim down and tone up, I don’t recommend ketogenic diets because they are impossible for most to maintain and they do not teach you how to sustain the weight loss.  In my opinion, a balanced approach is more likely to end in lasting weight loss.  That being said, the senior NCO lost significant amounts of weight and is still stable four months later.  I could not want to live in a world without bread, candy, fruit, pasta, potatoes, rice, and baked goodies such as cookies and cakes. This being said, I can, also, no longer recommend against them at this time.  I can’t wait to see the next roudn of research.

References

[1]
J. Buchhalter et al., “The relationship between d-beta-hydroxybutyrate blood concentrations and seizure control in children treated with the ketogenic diet for medically intractable epilepsy.,” Epilepsia Open, vol. 2, no. 3, pp. 317–321, May 2017. [PubMed]
[2]
A. Yuen, I. Walcutt, and J. Sander, “An acidosis-sparing ketogenic (ASK) diet to improve efficacy and reduce adverse effects in the treatment of refractory epilepsy.,” Epilepsy Behav, vol. 74, pp. 15–21, Sep. 2017. [PubMed]
[3]
S. Titre-Johnson et al., “Ketogenic diet in the treatment of epilepsy in children under the age of 2 years: study protocol for a randomised controlled trial.,” Trials, vol. 18, no. 1, p. 195, Apr. 2017. [PubMed]
[4]
T. Walczyk and J. Wick, “The Ketogenic Diet: Making a Comeback.,” Consult Pharm, vol. 32, no. 7, pp. 388–396, Jul. 2017. [PubMed]
[5]
H. Dashti et al., “Long-term effects of a ketogenic diet in obese patients.,” Exp Clin Cardiol, vol. 9, no. 3, pp. 200–5, Oct. 2004. [PubMed]
[6]
A. Paoli, “Ketogenic diet for obesity: friend or foe?,” Int J Environ Res Public Health, vol. 11, no. 2, pp. 2092–107, Feb. 2014. [PubMed]
[7]
D. Gomez-Arbelaez et al., “Resting metabolic rate of obese patients under very low calorie ketogenic diet.,” Nutr Metab (Lond), vol. 15, p. 18, Feb. 2018. [PubMed]
[8]
W. Yancy, M. Foy, A. Chalecki, M. Vernon, and E. Westman, “A low-carbohydrate, ketogenic diet to treat type 2 diabetes.,” Nutr Metab (Lond), vol. 2, p. 34, Dec. 2005. [PubMed]
[9]
G. Boden, K. Sargrad, C. Homko, M. Mozzoli, and T. P. Stein, “Effect of a Low-Carbohydrate Diet on Appetite, Blood Glucose Levels, and Insulin Resistance in Obese Patients with Type 2 Diabetes,” A, vol. 142, no. 6, p. 403, Mar. 2005 [Online]. Available: 10.7326/0003-4819-142-6-200503150-00006″ target=”_blank” rel=”noopener noreferrer”>http://dx.doi.org/10.7326/0003-4819-142-6-200503150-00006
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About the Author

ChuckH
I am a family physician who has served in the US Army. In 2016, I found myself overweight, out of shape, and unhealthy, so I made a change to improve my health. This blog is the chronology of my path to better health and what I have learned along the way.

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