The Absurdity, Brilliance, and Snags of the Ketogenic Diet: Part 1

The ketogenic diet is the latest fad and certainly a trending internet topic. It’s been touted as a panacea for just about every chronic disease. The medical community is certainly divided on the short- and long- term impacts and safety of the ketogenic diet. It defies common sense to dump loads of fat (particularly animal-based) into the body when the health message for decades was the opposite. I thought I would throw my hat in the ring and detail all the glories and concerns of going “keto”.
 
The ketogenic diet is not new. It was designed by a physician in the 1920’s as a therapeutic diet for epileptic patients. Believe it or not, the macronutrient ratio has changed little from then till now. It acquired a bad name in the previous decades because of the unintentional mishaps that came from inept monitoring and supplementation; largely ketoacidosis, constipation, vomiting, coma, death, and hyperlipidemia.
 
It started increasing in popularity in the last 20 years, mostly related to the attention brought by various “success” stories, such as Mary Newport, Dave Asprey, Charlie Abraham, etc.. Celebrities, athletes, doctors, and wellness clinicians are screaming the praises of this diet as it is associated with improving cardiovascular disease, diabetes, obesity, neurodegenerative diseases, metabolic syndrome, cancer, seizures, mitochondrial reparation, and cognitive decline.
 
What’s my verdict on the ketogenic diet? Like everything else- it depends. Your genetics, organ health, lifestyle, nutrient status, stress levels, sleep patterns, intentions, and diligence with the diet all play a role in the success, effectiveness, and safety of the ketogenic diet. Part One of this ketogenic series will detail what it is, the benefits, and who should steer clear.  

Let’s start with…
 
What Exactly Is a Ketogenic Diet?
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In general, the ketogenic diet alters the macronutrient consumption ratio to a high percentage of fat with a low percentage of carbohydrates and protein. The cells in the body are forced to utilize fat as the main fuel source since you’re providing little glucose (carbohydrates). The metabolic end-result?  Ketones. It was thought at one time that glucose was the preferred form of fuel for most cells (and many would argue it still is), including the brain.  Research is now showing that ketones are not only an acceptable fuel, but may be preferred, given it lightens the mitochondrial load and does not require insulin for metabolism (1). In essence, it might be more efficient in producing and harvesting energy than glucose (2).
 
There is no exact way to do the diet and the method of macronutrient distribution differs with different practitioners. I’ve seen clinicians emphasize a carbohydrate intake less than 60 gm per day, with less focus on protein. Others focus on specific percentages- for example, a typical distribution would entail 65% fat, 25% protein, and 10% carbohydrates.
 
This is a key point- depending on what you’re trying to do, depends greatly on what ratio you choose. Which leads me to... 

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​Why are you doing this and what are you trying to accomplish?
 
From my point of view, this splits you into two categories:
 
​   A) Those using it as a therapeutic diet for more serious conditions such as cancer, seizures, autism, traumatic brain injury, neurodegenerative disorders, brittle diabetics, etc.. In order for effective treatment, these individuals must strictly adhere to the diet with the ratio breakdown being extreme. The ratio is more stringent and resembles approximately 90% fat, 7% protein, and 3% carbohydrate.  The goals are vastly different than casual weight loss and requires close monitoring from a clinician, as more things can definitely “go wrong”.  In these cases, diet diligence, supplementation, and hypervigilance are incredibly important.

   B) Weight loss and less severe conditions (i.e. pre-diabetes, obesity, GI disorders, skin conditions, etc.) loosens the rope on macronutrient guidelines. The ratio breakdown is roughly: 60-70% fat, 15-25% protein, 10-15% carbohydrate. Although less severe than the therapeutic counterpart, things can and do go wrong when attempting this diet. 
Since the majority of people are falling into category B, the rest of this blog will focus on the different aspects and concerns of a modified ketogenic diet. I strongly recommend a clinicians’ help, if you are in category A, where the ratio of macronutrients is extreme and the likelihood of metabolic amiss is high. 

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What Are the Benefits of Going “Keto”?
 
The list is long, but here’s why the ketogenic diet is quickly gaining favor. I want to note that these possible benefits only happen with diet adherence. If you’re constantly wavering in and out of ketosis, you’re just dumping a bunch of fat calories on top of carbohydrate/protein calories. Wavering ketosis will not induce desirable, metabolic shifts. In other words, you have to get to where you want to go first with diet diligence. Potential benefits include:

• Decreased appetite; therefore, aids in weight loss and decreased visceral/abdominal fat (3).

 

• May favorably alter lipid profile (i.e. HDL, LDL, total cholesterol, etc.) (4).    

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• May improve cardiovascular health (i.e. blood pressure, inflammatory markers, decreases visceral/abdominal fat) (5).

 

• Reduces inflammation (6). Given inflammation is the root of most ailments, this is a big one.

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• Lowers glucose levels, improves insulin sensitivity and glucose metabolism, and (if done correctly) possibly improves neuropathy. Why? Ketones do not need insulin as the carrier into cells for fuel. Ketones cannot get glycosylated, hence a lower HgbA1C level (a diabetic, diagnostic marker) (7,8).

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• ​Improves mitochondrial function (9). This sounds like a bunch of fancy words, but I cannot express how important this is on so many levels. In essence, it improves your cell’s ability to generate energy. EVERYTHING YOU DO REQUIRES ENERGY. Mitochondrial dysfunction always leads to problems at some point and you always want your “energy factories” in tip top shape.

 

• May improve polycystic ovarian syndrome by favorably shifting testosterone and insulin levels, weight status, and the LH/FSH ratio (10).

 

• May beneficially shift neurotransmitter levels and have a neuroprotective role (11, 12).  

 

• Increases antioxidant activity, glutathione production, and decreases ROS production (reactive oxygen species) (13). What the heck does that mean? Basically, you’re creating an army of the ultimate Jedi fighters which wards off the bad guys who create metabolic havoc in your body.

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• Possibly beneficial for endurance athletes, with ketones serving as an alternative, nearly infinite fuel source (14).

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When The Ketogenic Diet Will Likely Not Vibe With Your Body
 
If the benefits are so great, why isn’t everyone on the ketogenic diet? First, it’s challenging to properly adhere to the ketogenic diet. I’ve also heard countless times certain people just don’t “feel good” on the diet (which could be due to poor execution). Individuals who should NOT attempt the ketogenic diet, or at minimum, be closely monitored by a clinician:

• You have a fatty acid metabolic disorder (i.e. primary carnitine deficiency, pyruvate carboxylase deficiency, porphyria, pyruvate carboxylase deficiency, MCAD, LCAD, SCAD, etc.). This is not commonly tested in newborns; therefore, most people aren’t even aware of an existing genetic condition. In addition, seek help for any genetic SNPs (single nucleotide polymorphism) that impacts fat metabolism such as the APOE, FTO, and PPAR. 

 

• Anyone with chronic, high stress. Yes, you read me right. The cortisol output from adrenals will induce elevated blood sugars, which counters ketone production. Furthermore, antagonizing your stress response system with the diet will contribute to an already compromised adrenal system. This unfortunately applies to insomniacs too as insufficient sleep can throw off your stress and hunger hormones and increase blood sugar levels.

 

• Pregnant or breastfeeding women.

 

• Anyone with liver and/or gallbladder issues.

 

• Kidney stones and/or kidney disease.

 

• Impaired gut function (seek help if this applies to you as the diet can be helpful for GI disorders).

 

• History of pancreatitis.

 

• Vegan and vegetarians proceed cautiously. Maintaining nutrient sufficiency and ketosis are real issues with this population. The "keto" path is not impossible, but a bit more challenging and requires a savvy keto-enthusiast.

 

• A lifestyle that is not conducive to healthy eating and supplementation adherence. 

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​Are you horrified or convinced the ketogenic diet is for you? With every great idea there is risk; so stay tuned for Part Two, where I will discuss my concerns and the process of getting into a modified ketotic state. 

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References:

1. Greco T, Glenn TC, Hovda DA, Prins ML. “Ketogenic diet decreases oxidative stress and improves mitochondrial respiratory complex activity.” J Cereb Blood Flow Metab. 2015 Oct 13. pii: 0271678X15610584. 
2. Prince A, Zhang Y, Croniger C, Puchowicz M. "Oxidative metabolism: glucose versus ketones." Adv Exp Med Biol. 2013;789:323-8. doi: 10.1007?978-1-4614-7411-1_43.
3. Libitum, Johnstone AM, et al. “Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad,” Am J Clin Nutr., 2008.
4. Adibhatla RM, Hatcher JF. “Altered lipid metabolism in brain injury and disorders.” Subcell Biochem. 2008;49:241-68. doi: 10.1007/978-1-4020-8831-5_9.
5. Cotter DG, Schugar RC, Crawford PA. “Ketone body metabolism and cardiovascular disease.” Am J Physiol Heart Circ Physiol. 2013 Apr 15;304(8):H1060-76. doi: 10.1152/ajpheart.00646.2012. Epub 2013 Feb 8.
6. Veech RL. "The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis,ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism.” Prostaglandins Leukot Essent Fatty Acids. 2004 Mar;70(3):309-19. 
7. Sasslow LR, et al. “A randomized pilot trial of a moderate carbohydrate diet compared to very low carrbohydrate diet in overweight or obese individuals with type 2 diabetes mellitus or prediabetes.” PloSOne. 2014;9(4):e91027.
8. Poplawski MM, et al. “Reversal of diabetic nephropathy by a ketogenic diet.” PloS One. 2011 Apr 20;6(4):e18604. doi: 10.1371/journal.pone.0018604.
9. Milder J, Manisha P. “Modulation of oxidative stress and mitochondrial function by the ketogenic diet.” Epilepsia Research. 2012;100:295-303.
10. Mavropoulos JC, Yancy WS, Hepburn J, Westman EC. “The effects of a low-carbohydrate, ketogenic diet on the polycystic ovary syndrome: a pilot study.” Nutr Metab (Lond). 2005 Dec 16;2:35.
11. Suzuki Y. “Beta-hydroxybutyrate alters GABA-transaminase activity in cultured astrocytes.” Brain Res. 2009 May 1;1268:17-23. doi: 10.1016/j.brainres.2009.02.074. Epub 2009 Mar 11.
12. Ruskin DN, Masino SA. “The Nervous System and Metabolic Dysregulation: Emerging Evidence Converges on Ketogenic Diet Therapy.” Front Neurosci. 2012. 6:33.
13. Jarret SG, Midler JB, Liang LP, Patel M. “The ketogenic diet increases mitochondria glutathione levels.” J Neurochem. 2008 Aug;106(3):1044-51.
14. Volek JS, Noakes T, Phinney SD. “Rethinking fat as a fuel for endurance exercise.” Eur J Sport Sci. 2015;15(1):13-20. doi: 10.1080/17461391.2014.959564. Epub 2014 Oct 2.