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What You Need to Know About the Typical Ketogenic Diet

It is important to mention, at the beginning of this article, that, when done correctly, there are beneficial aspects of a healthy ketogenic dietary approach. The points we are making in this article, apply to the typical ketogenic diet, that has become popular. It can present potential risk factors due to the source of foods (inflammatory animal and dairy fats) ; but also due to a failure to understand a basic physiologic principle: continuously remaining in nutritional ketosis, can cause side effects and is not optimally healthy long term. 

The ketogenic diet has been trendy for the last couple of years. The original use in the medical profession was intended to treat epilepsy and seizures in children. The ketogenic diet is comprised mainly of fats, low-to-moderate protein (which the body can turn to carbohydrate), and little-to-no carbohydrate.  As macronutrient distribution, this is approximately 80-90% of Calories from fat, 10-15% from protein, and 0-5% from carbohydrate. Many who have tried this diet were able to achieve weight loss. The weight loss is achieved through basic physiology. Insulin, which is a hormone that is secreted by the pancreas in response to carbohydrate in meals, is considered “the storage hormone.” 

In a fed state, insulin enables cells to take up glucose and utilize it as fuel. In the case of excess carbohydrate, some of this can be converted to fat by the liver and stored as triglyceride in fat tissue for use at a later time. Meals high in carbohydrate cause increasingly high amounts of insulin to be released. At the same time, the storage of dietary fats is increased as the body uses carbohydrate for energy production.  This is especially true in the case of individuals who are insulin-resistant, meaning their cells are less sensitive to insulin, further driving storage of fuels as fat in adipose tissue. Insulin also to some extent inhibits the release of fat from storage so that it is less likely to be used as fuel.  

Why Do People Regain Weight After a Ketogenic Diet? 

While the short-term benefits of the ketogenic diet may be attractive, weight lost in this manner may also be difficult to maintain, as many individuals who lose weight on a ketogenic diet rapidly regain weight once they shift back to their usual dietary habits.  What’s more, since the ketogenic diet is traditionally low in protein, people who lose weight tend to lose both fat as well as lean muscle mass. Since muscle is a metabolically active tissue, this decreases the body’s energy expenditure and lowers the basal metabolic rate, further exacerbating weight regain following a ketogenic diet. 

Potential Health Issues to Consider:

Digestive Side Effects and Gut Microbiome Compromise:

Due to the macronutrient distribution of the ketogenic diet, many people experience digestive issues while on this diet.  Fiber plays a major role in digestive function and gastrointestinal health. Since a large bulk of fiber comes from grain and legume sources (which are high in carbohydrate), when these foods are eliminated during a ketogenic diet, dieters may frequently become constipated.  

The increased fat content can also be problematic.  The liver produces a compound called bile, which is secreted into the digestive tract in response to meals in increasing amounts with relation to dietary fat content.  Since it may take a while for the liver to adjust, patients starting on a ketogenic may initially experience diarrhea and fat malabsorption (as well as malabsorption of minerals and fat-soluble vitamins).  Those who have gallbladder disease or have had their gallbladder surgically removed may experience more severe symptoms, as the gallbladder is the organ that stores and releases bile.

Continuously remaining in nutritional ketosis can actually cause counterproductive side effects, and is likely not optimally healthy in the long term.

Due to very limited carbohydrate intake, there is potential to develop nutrient deficiencies while following a long-term ketogenic diet.  This is particularly true for dieters who do not ensure intake of a wide variety of non-starchy vegetables, as each type of vegetable contains vitamins and minerals in varying amounts.  Another nutrient of particular concern is the previously mentioned fiber, which not only aids with digestion, but also provides nutrition for the gut microbiome, helping to keep the immune system functioning properly and keeping you healthy. 

High Cholesterol and Potential Cardiovascular Complications

Since the ketogenic diet dramatically limits the amount of carbohydrate and protein intake, naturally, the caloric difference is made up from increasing intake of fats.  If this is not done by increasing healthy fats, it is easy to consume more than the recommended amount of saturated fat in a day. Saturated fats are naturally higher in animal products such as meat, full-fat dairy, and eggs, and are associated with increased LDL cholesterol and risk for heart disease and stroke.  When it comes to fat intake, you should consume no more than 6% of daily Calories from saturated fat. For 2000 Calories per day, this equates to approximately 13 grams of saturated fat (8 slices of bacon contain approximately 12 grams of saturated fat). 

Important:  If you are thinking to follow a ketogenic diet and have a so-called “cheat day,” you may want to think again.  A recent study shows that 1 week consumption of a high fat diet followed by a challenge with a 75 gram glucose drink led to blood vessel damage due to relative glucose intolerance caused by the high fat diet.  

Inflammatory Reactions 

Increased animal fat and protein intake is the activation of inflammatory response, increased oxidative stress, and biological aging.   

Fatty Liver 

The ketogenic diet dramatically increases dietary fat content.  Since the liver is the main organ in the body that processes fats, this type of diet has the potential to put increased stress on those with underlying liver disease, such as NAFLD (non-alcoholic fatty liver disease), cirrhosis, or hepatitis.  Additionally, many people embarking on a ketogenic diet increase the amount of protein in the diet (with increased intake of meats and eggs) relative to carbohydrates. Since the kidneys are involved in processing protein, those with chronic kidney disease (especially advanced stages) or those nearing renal failure who have not started dialysis yet should speak with their physicians prior to considering a ketogenic diet.  

Other Factors: 

Furthermore, data obtained from a large cross-sectional study showed a relationship between lower carbohydrate diets and increased risk of cardiovascular disease, cerebrovascular events, and cancer mortality.  According to the data, risk was increased for non-obese individuals compared to obese individuals.  

The ketogenic diet leads to the production of ketone bodies from fat metabolism, which increases overall acidity of the blood.  Patients with type 1 diabetes or type 2 diabetics with decreased insulin production who rely on external insulin to maintain blood sugar within desired range should be cautious with ketogenic diets.  This is due to a condition known as ketoacidosis, which can be dangerous, leading to damage of kidney/liver/and brain tissue, and can even be deadly in these individuals. They should seek close medical supervision prior to and during the diet, and regularly monitor blood sugar and ketone levels to help prevent serious side effects.

Conclusion and the CWLI Approach to Keto

Fact: We are NOT promoting the Keto diet!Main reason: It can cause “diet induced” inflammation; it cannot be sustained long term without possible health complications.Fact: Monitoring ketosis levels was part of our patients’ assessment since the beginning of CWLI- over 10 years ago.Main Reason: To monitor fat tissue break down, to assess the need in adjusting diabetic medication, and to monitor kidney function.Fact: Ketosis level should not be expected to be the same for everyone.Main Reason: Ketosis is determined by health status, weight loss goals, medication use, and variations in food intake.Fact: We promote an individualized anti-inflammatory diet (for some it may mean low carb) and targeted supplementationMain Reasons:* It causes fast but sustainable weight loss.* It addresses the root cause of metabolic dysfunction* It includes a nutrient rich and balanced food intake based on a patient’s specific metabolic needs* It delivers supplementation to help reverse chemical and hormonal imbalances that lead to weight gain and weight loss resistance.* It focuses on long term maintenance and prevention.

Dr Lidia Adkins, PKT, DC, CFMP
Suzanne Doad, MS, RD, LDN