Ketogenic Diet (Keto) - Ineffective and Dangerous

[ChicagoGranny]

Dr. Shivam Joshi:

A physician's warning on the keto diet

... leading the diet to straddle the increasingly blurred lines between faddist snake oil and sanctified medical therapy.

By avoiding carbohydrates altogether, blood sugar levels do not spike, but the underlying glucose resistance may still be present. Although some small non-randomized studies show improvements with the diet, a larger meta-analysis of diabetic patients on either the ketogenic diet or a high-carbohydrate, low-fat diet for more than one year showed no difference in hemoglobin A1cs or glycemic levels between the two diets. ...

... they can induce a diuretic-like response, causing dieters to lose fluid-related weight, especially during the beginning of the diet. Those early results can serve to positively reinforce dieters and may be crucial in deciding whether to continue dieting, particularly in the face of restrictive dietary options and the malaise associated with the transition ...

An oft-cited meta-analysis comparing low-carb ketogenic diets to low-fat diets showed a difference in weight-loss of less than a kilogram after twelve months – a negligible difference. Interestingly enough, another, more-recent, meta-analysis showed no difference in results between low-carb and high-carb diets on weight – or blood sugar levels – after one year. ...

One of my concerns is the unnaturally high amount of fat consumed to maintain ketosis. If the diet had another name, it would be called “the fat diet” as 70-80 percent of calories per day come from fat. The only native population eating this much fat were the Inuit, who were forced to subsist on blubber out of necessity. And perhaps because of the high amounts of saturated and trans fats consumed, the Inuit experienced – despite popular misconceptions – a higher rate of heart disease, strokes, and death compared to non-Inuit and Western populations. The opportunity cost of not eating fruits, vegetables, and complex carbohydrates may have also contributed to their heightened risk.

Currently, there is no long-term data on the safety of the keto diet in adults. The keto diet may not be worth pursuing, even for diabetics or the obese, if we are mortgaging those diseases for higher rates of heart disease or colon cancer, a possibility given the low amounts of fiber consumed on these diets.

... children have developed kidney stones, acidosis, fractures and stunted growth. At the more serious end of the spectrum, children on the diet have died from arrhythmias arising from selenium deficiency and pancreatitis. The possibility of these side effects and possibly others yet to be discovered may tilt the diet out of favor.

Before embarking on a diet with known adverse effects in children, uncertain long-term safety in adults, and equivocal benefits when compared to other dietary strategies, both patients and physicians alike would behoove themselves to remember that diabetes and obesity are not a product of ketone deficiency but the symptom of caloric excess, dietary indiscretion, and torpor. Let food be thy medicine – but not if it involves a Faustian bargain of your health.

Shivam Joshi is a nephrology fellow.

Full article: https://www.kevinmd.com/blog/2018/07/a- ... -diet.html

There was another article in the NYT in the last few days warning that the keto diet is dangerous. I can't find the article at the moment.

[Snoregone Conclusion]

Even in what you posted directly in here, there’s variance in what’s being referred to as a ketogenic diet, from no carbs to unstated low carbs.

History has shown self-reported dietary intake is horribly inaccurate, and meta analyses seem improbable to give good information.

Strictly speaking, on a day-to-day basis our bodies don’t need carbs at all, though we need some every so often if only for our gut flora to remain healthy and balanced.

More reasonable is a Low Carb High Fat diet, where most of the fats are the healthy oils/fats, and low-carb veggies are eaten, with very little fruit. This also means not a huge amount of protein (medium amount, not Atkins) as above a certain percentage of protein our body converts the excess to sugars, defeating the purpose.

It’s certainly not easy to sustain such a long-term pattern in the US if you eat anywhere but at home.

Even then, to keep flexible, there should be times where the diet has breaks in the pattern.

[igotsuckeredtoo]

Thanks for this. Moderation in all things.

The idea that self reporting is "horribly inaccurate" is a canard just as dangerous as the ketone diet fad. Your body does not convert protein to sugar. It converts carbohydrates to sugar and then fat if it is not used quickly enough. Most people, especially the elderly don't get enough protein and too much carb.

[nicholasjh1]

Dr. Shivam Joshi:

A physician's warning on the keto diet

... leading the diet to straddle the increasingly blurred lines between faddist snake oil and sanctified medical therapy.

By avoiding carbohydrates altogether, blood sugar levels do not spike, but the underlying glucose resistance may still be present. Although some small non-randomized studies show improvements with the diet, a larger meta-analysis of diabetic patients on either the ketogenic diet or a high-carbohydrate, low-fat diet for more than one year showed no difference in hemoglobin A1cs or glycemic levels between the two diets. ...

... they can induce a diuretic-like response, causing dieters to lose fluid-related weight, especially during the beginning of the diet. Those early results can serve to positively reinforce dieters and may be crucial in deciding whether to continue dieting, particularly in the face of restrictive dietary options and the malaise associated with the transition ...

An oft-cited meta-analysis comparing low-carb ketogenic diets to low-fat diets showed a difference in weight-loss of less than a kilogram after twelve months – a negligible difference. Interestingly enough, another, more-recent, meta-analysis showed no difference in results between low-carb and high-carb diets on weight – or blood sugar levels – after one year. ...

One of my concerns is the unnaturally high amount of fat consumed to maintain ketosis. If the diet had another name, it would be called “the fat diet” as 70-80 percent of calories per day come from fat. The only native population eating this much fat were the Inuit, who were forced to subsist on blubber out of necessity. And perhaps because of the high amounts of saturated and trans fats consumed, the Inuit experienced – despite popular misconceptions – a higher rate of heart disease, strokes, and death compared to non-Inuit and Western populations. The opportunity cost of not eating fruits, vegetables, and complex carbohydrates may have also contributed to their heightened risk.

Currently, there is no long-term data on the safety of the keto diet in adults. The keto diet may not be worth pursuing, even for diabetics or the obese, if we are mortgaging those diseases for higher rates of heart disease or colon cancer, a possibility given the low amounts of fiber consumed on these diets.

... children have developed kidney stones, acidosis, fractures and stunted growth. At the more serious end of the spectrum, children on the diet have died from arrhythmias arising from selenium deficiency and pancreatitis. The possibility of these side effects and possibly others yet to be discovered may tilt the diet out of favor.

Before embarking on a diet with known adverse effects in children, uncertain long-term safety in adults, and equivocal benefits when compared to other dietary strategies, both patients and physicians alike would behoove themselves to remember that diabetes and obesity are not a product of ketone deficiency but the symptom of caloric excess, dietary indiscretion, and torpor. Let food be thy medicine – but not if it involves a Faustian bargain of your health.

Shivam Joshi is a nephrology fellow.

Full article: https://www.kevinmd.com/blog/2018/07/a- ... -diet.html

There was another article in the NYT in the last few days warning that the keto diet is dangerous. I can't find the article at the moment.

Not sure how much these studies are effected, but under low carb conditions protein can be converted to carbs as well, and from the studies I've seen looking at this they don't control for that very well. A high protein high fat diet is not ketogenic.

[ChicagoGranny]

Pet peeve: Unnecessarily quoting the entire contents of a long post.

[chunkyfrog]

Editing is haaaard . . .

[Janknitz]

An opinion piece by an uninformed doctor who hasn't bothered to even read all the studies he cites.

Joshi says

Although some small non-randomized studies show improvements with the diet, a larger meta-analysis of diabetic patients on either the ketogenic diet or a high-carbohydrate, low-fat diet for more than one year showed no difference in hemoglobin A1cs or glycemic levels between the two diets

Here's the "larger meta-analysis" he cites: https://www.cambridge.org/core/journals ... A9CE860783 I can only see the abstract which doesn't address A1C's but it showed that a Very Low Carbohydrate Ketogenic Diet (VLKD) showed marked improvement in decreased body weight, total cholesterol HDL and LDL-C, and diastolic blood pressure. The abstract concludes "Individuals assigned to a VLCKD achieve a greater weight loss than those assigned to a LFD in the long term; hence, a VLCKD may be an alternative tool against obesity." I don't see anything addressing HBA1C or glycemic levels compared to a low fat diet. Perhaps the full article did, but it wasn't significant enough to note in the abstract.

Here's an actual peer-reviewed study (not someone's opinion) that addresses it directly: https://diabetes.jmir.org/2017/1/e5/ which concludes "nutritional ketosis can be highly effective in improving glycemic control and weight loss in adults with T2D while significantly decreasing medication use"

Oh, but that's a short-term study, so one may argue it doesn't count. Here's the one year follow-up: https://link.springer.com/article/10.10 ... 018-0373-9

After 1 year, patients in the CCI, on average, lowered HbA1c from 7.6 to 6.3%, lost 12% of their body weight, and reduced diabetes medicine use. 94% of patients who were prescribed insulin reduced or stopped their insulin use, and sulfonylureas were eliminated in all patients. Participants in the UC group had no changes to HbA1c, weight or diabetes medicine use over the year. These changes in CCI participants happened safely while dyslipidemia and markers of inflammation and liver function improved. This suggests the novel care model studied here using dietary carbohydrate restriction and continuous remote care can safely support adults with T2D to lower HbA1c, weight, and medicine use.

(CCI =Continuous Care Intervention with support and a ketogenic diet, UC = Usual Care).

... they can induce a diuretic-like response, causing dieters to lose fluid-related weight, especially during the beginning of the diet. Those early results can serve to positively reinforce dieters and may be crucial in deciding whether to continue dieting, particularly in the face of restrictive dietary options and the malaise associated with the transition ...

Guess I lost 75 lbs of water weight and kept it (mostly) off for 7 years.
Just had my annual physical this week--all my markers are great--insulin resistance under control, HBA1C 5.2. I'm in the best health of my life. Contrast that to seven years ago, when I was truly on death's doorstep.

Guess I'll continue to LIVE--dangerously.

[raisedfist]

Keto diet is great if you are large aka obese...if you are just barely above normal weight, there is no need for it.

[Midnight Strangler]

Thanks for posting this article. A friend and I went on a ketogenic diet in 1996. We both lost a good bit of weight. After a year, heavy business travel got me off of it, and I gained much of the weight back.

In 2014, I retired with a goal of losing weight. I had a strong suspicion that a keto diet is not healthy, and it certainly wasn't fun. This time, I just ate whatever I liked, but reduced the serving sizes. I met my weight loss goal quickly and maintain it 4+ years later. My wife and I like to eat out a lot. We bring half of our meals home or share a meal.

Calorie restriction works, and I think it can be done in a more healthy and fun way than a keto diet. Looking at some of the studies of "successful" keto diets, you see things like this:

outpatient protocol providing intensive nutrition and behavioral counseling, digital coaching and education platform, and physician-guided medication management

That's severe IMO, and may have more to do with the "good" results than the keto diet itself.

[palerider]

Thanks for this. Moderation in all things.

Especially moderation.

[palerider]

Pet peeve Unnecessarily quoting

Agreed

[palerider]

Guess I lost 75 lbs of water weight and kept it (mostly) off for 7 years.

That's only nine and a third gallons! easy peasy!

[Janknitz]

That's severe IMO, and may have more to do with the "good" results than the keto diet itself.

Not severe. Supportive. I did it myself, being horribly sick and dying was severe. This is a breeze!

[Arlene1963]

Agree with Janknitz.
I've experienced very good results from lowering carbohydrates and increasing good fats. I'm maintaining weight loss (going on for 3 years now), have lots of energy, and am very rarely tempted to snack between meals because I don't get hungry. If I do feel like a snack I eat some macadamia nuts or a few olives, sometimes half an avocado, and find that satisfies me for way longer than say a rice cake or banana did in the past.
Recent blood work indicated excellent cholesterol levels, normal blood glucose.
Fortunately my sleep is great thanks to CPAP and that really helps me too with keeping the weight off. I doubt I will ever go back to eating the number and type of carbohydrates I was a few years ago, I just feel way too good eating fewer. It suits me better. If I were feeling depressed and deprived I might feel differently but since I feel the exact opposite I will stick with this. Each to their own.

[chunkyfrog]

Moderation and common sense is a good plan to live by.
Not glamorous or exciting--but it is mostly harmless.
Also easy, and not terribly expensive.
It gets so little press because it is hard to monetize.
Remember, if something is heavily promoted--they probably want your money.