Month: August 2020

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Therapeutic Ketogenic Diet and How it Differs from “the Keto Diet”

In addition to the several types of therapeutic ketogenic diets mentioned in the previous post, such as the Classic Ketogenic Diet (KD), the Modified  Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) used in the treatment of epilepsy and seizure disorder and as adjunct treatment in glioblastoma, there is another type of therapeutic ketogenic diet used in the treatment of type 2 diabetes and for weight loss which is referred to in the literature as a Very Low Carbohydrate Diet (VLCD). This post outlines two examples of this type of therapeutic ketogenic diet, and how it differs considerably from the popularized “keto diet”.

When compared with a Very Low Carbohydrate Diet (VLCD), the popularized “keto diet” which focuses on high intake of eggs and fatty cuts along with copious amounts of added fat in the form of ‘fat bombs’ and ‘bulletproof coffee’ is like a caricature compared with a portrait.  A portrait seeks to accurately represent physical attributes, and a caricature uses hyperbole to exaggerate some, and over-simplify others. 

This new article picks up from the previous one in outlining another type of therapeutic ketogenic diet used for putting type 2 diabetes into remission as well as for weight loss, and how it is very different from the popularized “keto diet”.

A Therapeutic Ketogenic Diet

A ketogenic diet is one that induces and sustains a state of ketosis which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate. What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.

In reference to the treatment of type 2 diabetes and obesity, ketogenic diets are often referred to in the literature as a ”Very Low Carbohydrate Dies (VLCD)“, which is where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake[1]. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis.

Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 — 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets  used in the treatment of epilepsy, seizure disorder and glioblastoma). In a Very Low Carbohydrate Diet (VLCD) used in the treatment of type 2 diabetes, BHB levels are usually set between 1.5-3.0 mmol/L, a level described as nutritional ketosis [2].

A drug or diet is said to be therapeutic when it is used in the treatment of a disease or medical condition(s). When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [3].

Use of a Very Low Carbohydrate Diet (VLCD) as Medical Nutrition Therapy in the treatment of type 2 diabetes is recognized by numerous organizations around the world, including the European Association for the Study of Diabetes (EASD).

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included both a low carbohydrate (LC) and very low carbohydrate (VLC) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report, and has included both in their 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  This year,  Diabetes Canada released a Position Statement outlining that a low carbohydrate (LC) and very low carbohydrate diet (VLCD) are both safe and effective treatment for non-pregnant or lactating adults with type 2 diabetes.

The American Diabetes Association’s  Consensus Report defines low carbohydrate and very low carbohydrate as follows;

”In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories [4].”

and

”In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories [4].”

Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate,  and very low carbohydrate diets as <50 g of carbohydrate per day [5].

Very Low Carbohydrate Diet (VLCD) for Treatment of Type 2 Diabetes

Back in 2018, the American Diabetes Association cited Virta Health’s one-year study data [6] as evidence for the safety and efficacy of a Very Low Carbohydrate Diet (VLCHD) in lowering blood sugar and diabetes medication usage and the new Diabetes Canada’s recommendations refers to the same study. As a result, Virta Health’s study is a good place for defining what a Very Low Carbohydrate Diet (VLCD) for the treatment of type 2 diabetes looks like.

Note: It should be noted that at the time the ADA’s 2019 Standards of Medical Care in Diabetes was published, Virta Health’s 2-year data had not yet been published, so the ADA and in turn, Diabetes Canada recommendations which were based on it, as well as other international organizations support for low and very low carbohydrate diets were only able to say conclusively that low carbohydrate diets and very low carbohydrate diets were safe and effective both in managing weight, as well as lowering glycated hemoglobin (HbA1C) in people with type 2 diabetes over the short term (<3 months). 

Virta Health’s Approach

As covered in this article on my affiliate site about Virta Health’s 2-year update and in this article with their 1-year update , subjects in their studies typically ate;

  1. <30 g per day of total dietary carbohydrate
  2. daily protein intake was targeted to a level of 1.5 g / kg based on ideal body weight
  3. Participants were coached to incorporate dietary fats until they were no longer hungry (i.e. to satiety)

Note (August 31, 2020): To put the protein requirements in perspective, a male whose ideal body weight is 150 pounds (68 kg) would be eating over 100 g of protein per day and a female whose ideal body weight is 135 pounds (61 kg) would be eating 92 g of protein per day.  That is, protein is targeted for its nutrient-density and satiety, and fat is incorporated only until satiety is reached.

Phinney and Volek’s Approach

Dr. Stephen Phinney MD, PhD, a medical doctor and Dr. Jeff Volek, RD, PhD a Registered Dietitian with a PhD have decades of combined scientific and clinic research experience in the area of low carbohydrate diets. In 2011 they published their expert guide titled The Art and Science of Low Carbohydrate Living [7] documenting the clinical benefits of carbohydrate restriction and how it can be used for weight loss.

In Phinney and Volek’s book [7], the Very Low Carbohydrate Diet (VLCD) outlined is one that is higher protein during the weight loss phase than during the weight maintenance stage, with ~30% of caloric intake coming from protein during weight loss, but which decreases to ~21% of caloric intake during weight maintenance. Fat is 60% of calories during the weight loss phase, and is increased to 65-72% during weight maintenance. Carbohydrate intake is kept very low (7.5-10% of calories for men, 2.5-6.5% of calories for women) in order to induce nutritional ketosis.

The reason dietary fat intake is lower during the weight loss phase in Phinney and Volek’s approach is to allow for the using of body fat stores for energy.

In Phinney and Volek’s approach;

  1. Carbohydrate intake is 7.5-10% of calories for men, 2.5-6.5% of calories for women
  2. Protein intake is up to 30% of calories during weight loss, 21% during weight maintenance
  3. Fat is 60% of calories during weight loss, 65-72% of calories during weight maintenance

Note (August 31, 2020): Protein intake for someone eating 2000 kcals per day is 150 g and for someone eating 1700 kcals per day is 141 g per day. Again, protein is targeted for its nutrient-density and satiety, and fat is only 60% of calories during weight loss.  This is very different than the popularized “keto diet”.

Popularized “Keto Diet”

The popularized “keto diet” is described as 70 – 80% fat, 15-20% protein* and 5% carbohydrate, with websites and articles promoting it frequently show plates laden with bacon and eggs, large fatty steaks with added butter melting on top, and loads of whipping cream over berries, and lots of avocado.

*while many “keto” proponents still stick with the lower protein intake [8], others have more recently increased the protein macro to 20% of calories, with fat at 70%.

This popularized “keto diet” is not the Very Low Carbohydrate Diet (VLCD) used by either Virta Health for putting type 2 diabetes into remission, or the VLCD approach used by Phinney and Volek for weight loss.

The popularized “keto diet” has ~50% less protein than a Very Low Carbohydrate Diet (VLCD) and ~20% more fat which has twice the energy density as protein.

Furthermore, the popularized “keto diet” is a very high fat, very low carbohydrate diet and is often promoted along with periods of intermittent fasting (IF), as frequent periods of less than 24 hours, or longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day), alternate day fasting, 36 hour fasts, or 42 hour fasts. This approach may suit some, but one has to ask if only eating ~1/3 of the time, is any weight loss really due to eating super high fat all the time, or due to the periods of fasting?

Like a caricature, the “keto diet” exaggerates some aspects of a Very Low Carbohydrate Diet (VLCD) and over-simplifies others. It exaggerates the fallacy that one needs to add extra fat into everything in order to lose weight, and overlooks the satiety of protein.

[Personal note: Approximately 1/3 of clients come to me for support after having followed this popularized “keto diet” without the fasting, and having failed to lose more than a bit of weight initially, or having gained weight.] 

Final Thoughts

There is no one-sized-fits-all low carb or ketogenic diet for weight loss, because each person’s nutrition needs are different. As covered in the preceding article, for those seeking safe and effective weight loss, there are a range of low carbohydrate diets available to choose from, with some that includes periods of ketosis, and others that don’t.

For those seeking to put type 2 diabetes into remission, a well-designed ketogenic diet using the Virta Health approach, or for weight-loss using Phinney and Volek’s approach are both safe and effective, if individualized for each person and done with adequate oversight. 

Remember, if you are taking any medication for type 2 diabetes, please read this article for why it can be dangerous to begin a very low carbohydrate diet (VLCD) / ketogenic diet without the involvement of your diabetes team.

More Info?

If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

  1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13
  2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
  4. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  5. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
  6. Hallberg SJ, McKenzie AL, Williams PT, et al. Effectiveness and safety of a novel care model for the management of type 2 diabetes at 1 year: an  open-label, non-randomized, controlled study. Diabetes Ther 2018;9:583—612
  7. Volek JS, Phinney SD, The Art and Science of Low Carbohydrate Living: An Expert Guide, Beyond Obesity, 2011
  8. Zoe Harcombe, LCHF and Butter, January 29, 2018, https://www.zoeharcombe.com/2018/01/lchf-and-butter/

Copyright ©2020 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

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The Stereotypical High Fat Keto Diet is Only ONE Type

There is a common, but mistaken belief that there is such as thing as “THE keto diet” (singular) — which is high in fat of all types, including cream, butter, bacon, avocado and fatty cuts of meat. In fact, there are a wide range of “keto diets” (plural) — including several different therapeutic ones, as well as those that have been popularized the last several years for weight loss.  This article will explains the range of ketogenic diets that are available, and what they are used for as well as the unintended consequence of believing that a “keto diet” has to be high in fat.

What is a Ketogenic Diet?

A ketogenic diet is one that induces and sustains a state of ketosis, which is a natural metabolic state where the body burns fat as its primary fuel, rather than carbohydrate.

There are a number of different therapeutic ketogenic diets, as well as a number of weight-loss ketogenic diets. 

What makes any diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains.

This bears repeating.

A ketogenic diet is determined solely on the basis of how much carbohydrate it contains, and not on how much fat in contains.

Ketogenic diets, which are also referred to in the literature as “very low carbohydrate diets” are where carbohydrate intake is limited to 20-50 g per day or 10% of total energy intake [1].  It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate and at this very low level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis. 

Ketosis is where the ketone betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L — and up to 4.0 mmol/L for therapeutic ketogenic diets used in the treatment of epilepsy, seizure disorder and glioblastoma.

Nutritional ketosis used predominantly for weight loss is usually set with BHB levels between 1.5-3.0 mmol/L [2].

Low carbohydrate diets are those where carbohydrate intake is limited to < 130 g per day or < 26% of total energy intake [1] and moderate carbohydrate diets are where carbohydrate intake is limited to 130—225 g per day or 26—45% of total energy intake [1].

Again, the amount of fat in the diet has nothing to do with a diet being ketogenic — only the amount of carbohydrate it contains.

Therapeutic Ketogenic Diets

First of all, what does “therapeutic” mean?

Something is therapeutic when it is used in the treatment of a disease. This may be a pharmaceutical drug or a diet.  What makes a diet therapeutic is that it is used to treat a medical condition, or conditions.

A therapeutic diet may be prescribed by a Physician, and implemented by a Dietitian or the Physician themselves.  When implemented by a Dietitian, a therapeutic diet is referred to as Medical Nutrition Therapy (MNT) [3].

The first therapeutic ketogenic diet was used in the 1920s for the treatment of epilepsy. Physicians at Harvard Medical School had begun experimenting with periods of extended fasting as a treatment, and discovered that seizures improved after 2-3 days. In 1921 , Dr. R.M. Wilder[3] used a very high fat, low carbohydrate, and restricted protein diet in a series of patients with epilepsy, and found that it was as effective as fasting and had the advantage that it could be maintained for much longer a period of time than fasting.

The percentage of carbohydrate, fat and protein in what has since become called the “classic” Ketogenic Diet (KD) was worked out by Dr. M.G. Peterman in 1925 [4] and are the same as used today.  In the classic KD, the total amount of calories are matched to the number of calories the person needs. Protein is usually determined as being 1 g of protein per kg body weight, 10-15 g of carbohydrate per day total, and the remainder of calories provided as fat.  For very young children, the diet may be prescribed based on body weight (e.g. 75-100 calories for each kg (2.2 pounds) of body weight. 

Since the 1920s, several other therapeutic ketogenic for the treatment of epilepsy and seizure disorder have been developed, including the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD). These are all high fat diets, but differ in the amount of protein they contain. They are all very low carbohydrate diets, which is by definition what makes them ketogenic.

The classic Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs. In the classic Ketogenic Diet, 90% of calories come from fat, 6% from protein, and only 4% of calories come from carbohydrate.

The Modified Ketogenic Diet (MKD) has a 3:1 ratio i.e. 3 parts fat for every 1-part protein and carbohydrate. In a Modified Ketogenic Diet, 80-90% of calories come from fat, 12-15% of calories come from protein, and 5-6 % calories come from carbohydrate[5].

The Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbohydrate.  In a Modified Atkins Diet, carbohydrates are restricted to <15 g / day for children, <20 g / day for adults. In a Modified Atkins Diet, 60% of calories come from fat, 30% of calories come from protein, and 10% of calories come from carbohydrate[5].

As well as their use in epilepsy and seizure disorder, any of the above therapeutic ketogenic diets may be prescribed for patients as adjunct treatment in glioblastoma, or as adjunct treatment in Alzheimer’s disease.

These high fat diets are not weight loss diets. These are therapeutic ketogenic diets used with the goal of producing high amounts of ketones (> 4.0 mmol/L / 40 mg/dl) for therapeutic reasons.

Other Types of Therapeutic Ketogenic Diets – for treatment of type 2 diabetes and obesity

In addition to the three types of therapeutic ketogenic diets above, ketogenic diets where carbohydrate is restricted to 50g of carbohydrates per day or less are considered Medical Nutrition Therapy (MNT) in the treatment of type 2 diabetes.

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included the use of a very low carbohydrate (ketogenic) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report and both the 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  In addition, Diabetes Canada released a Position Statement in April of this year outlining that a low carb and very low carb / keto (<50 g of carbohydrates per day) are both safe and effective treatment for adults with diabetes. 

According to the American Diabetes Association, what makes a diet low carbohydrate (LC) or very low carbohydrate (VLC) / ketogenic is defined by the amount of carbohydrate contained in the diet, not the amount of fat. The American Diabetes Association’s  Consensus Report defines low carb and very low carb as follows;

“In this review, a low carbohydrate (LC) eating patterns is defined as reducing carbohydrates to 26-45% of total calories [6].”

and

“In this review a very low carbohydrate (VLC) eating pattern is defined as reducing carbohydrate to <26% of total calories [6].”

Diabetes Canada also defines low carbohydrate and very low carbohydrate diets in terms of the amount of carbohydrate the diet contains. Low carbohydrate diets are defined as less than <130 g of carbohydrate per day or <45% energy as carbohydrate,  and very low carbohydrate diets as <50 g of carbohydrate per day [7].

Weight-Loss “Keto” Diets

There are a wide range of weight-loss approaches that have a ketogenic (keto) component to them.

The 1997 Protein Power[8] published by Dr. Micheal Eades and his wife Dr. Mary Dan Eades is a low carb, high protein, moderate fat ketogenic diet. In fact, the authors warn in the book that eating a large number of calories as fat would make it impossible to lose weight, so this is not a high fat diet at all.

The New Atkins For a New You [9], was redesigned in 2010 by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, and while considered a low carbohydrate high fat, moderate protein weight loss diet, it has 4 phases, with only the first phase being ketogenic (20-50 g carbs per day), but only for two weeks. This first stage is where the Modified Ketogenic Diet (MKD) used in epilepsy and seizure disorder came from — but as a weight-loss diet, the high fat stage in The New Atkins for a New You is very short lived. In phase two, more carbohydrate is added (nuts & seeds, berries, cherries and melon, cheese,  dairy products, legumes (pulses), tomato juice and vegetable cocktail) and this level is maintained until close to goal weight when higher carbohydrate amounts are added in phase 3, then phase 4. It is only higher fat for the first two weeks. 

Then there is the 2013 Real Meal Revolution [10] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot which is a handbook on the Banting lifestyle (which originated in the late 1800s), with foods broken down into green list, orange list and red list, with varying levels of carbohydrate intake.

Note: there is also the 2014 Bulletproof Diet by former Silicon-Valley biohacker, Dave Asprey but since he doesn’t have a clinical background, I have not included it.  That said, the diet is very high fat and is where “bulletproof coffee” (with added butter and coconut oil) comes from.

In 2016, Dr. Jason Fung, a Toronto nephrologist (kidney specialist) wrote the Obesity Code [11] which promotes a high fat version of a very low carb / keto diet, which is used in conjunction with his 2016 book written with Jimmy Moore titled The Complete Guide to Fasting [12]. In 2020, Fung published Life in the Fasting Lane [13], written with Eve Meyer and Megan Remos which builds on his approach of using a low carb high fat diet along with intermittent fasting.

In 2014, the web site “Diet Doctor” was launched by Dr. Andreas Eenfeld. This was initially mostly with articles translated from his Swedish site and later added content from a variety of other people, including Dr. Jason Fung, Dr. Eric Westman and Dr. Ted Naiman.  In 2017, Eenfeld wrote his own diet book titled Low Carb High Fat Food Revolution [14], which promoted a high fat version of a very low carb / ketogenic weight loss diet.  Later, Dr. Eric Westman went on to found his own Adapt weight loss program which is a very low carb / keto, moderate protein, moderate fat approach and Dr. Ted Naiman went on to write his P:E Diet [15] which promotes a low carb, high protein, low fat approach.

Of ketogenic weight-loss diets outlined above, the two that promote a very high fat intake are Dr. Jason Fung’s approach, and the “Diet Doctor” approach. While both fat and protein result in satiety (not feeling hungry), fat has almost two and a half the caloric density as protein. In addition, fat can trigger the reward system of the brain in the same way carbs do, resulting in many over-eating fat, especially added fat. What many people fail to take into consideration is that both of these approaches also promote periods of intermittent fasting (IF) which as Diet Doctor teaches may be frequent periods of less than 24 hours, to longer fasting periods which may include 5:2 (5 days of normal diet, 2 days restricting total calories to 500 per day) or alternate day fasting, as well as two types of fasts that Dr. Fung promotes, including 36 hour fasts, and 42 hour fasts. If one is only eating ~1/3 of the time, is any weight loss really due to the high fat diet, or the fasting?

“In our clinic, we will often recommend 36-hours fasts 2-3 times per week for type 2 diabetes.” ~Dr. Jason Fung

[ADDED NOTE, August 24, 2020: a well-formulated ketogenic diet such as used by Virta Health (covered here and here) which is high in fat and moderate in protein but that consists of a diet of real, whole food is not the same as popularized “keto diets” high in fat and moderate protein, but that consist of lots of added fat in both food and beverages. There is more to a well-designed ketogenic diet for remission of type 2 diabetes and obesity than macros, alone.

August 27, 2020: There is a fundamental difference between a well-designed ketogenic diet that is high in fat and that is comprised of real, whole food — and the popularized “keto diet”, which is all about added fat. It’s not about macros, but nutrients.]

The Stereotypical High Fat Keto Diet is Only ONE Type

Over the last several years, about 1/3 of people that come to me do so after following “the keto diets” without realizing that there is not just one.  Most lost some weight initially on this high fat diet, and then stalled — and quite a few actually ended up gaining weight.

Whether following Dr. Fung’s approach or the Diet Doctor approach, people reported eating 75% fat, 15% protein and 10% carbohydrate — which is essentially a hybrid between the Modified Ketogenic Diet (MKD) and the Modified Atkins Diet (MAD) which as mentioned above are NOT weight loss diets — in fact, they were designed to not result in weight loss. These high fat, moderate protein diets are diets are solely intended to produce large amounts of ketones for therapeutic purposes. 

It is no wonder high fat “keto” diets don’t deliver weight loss results. That’s not what they were designed to do! 

Unless these high fat “keto” diets are combined with the frequent periods of <24 hours of fasting, >24 hour periods of fasting several times per week, weight loss is unlikely to occur — unless as byproduct of the higher satiety of the fat, and over all eating less food.

Losing Body Fat is Not About Eating Less Carbs and More Fat!

If we want to lose body fat, then eating food that is very high in dietary fat won’t accomplish that — UNLESS one is only eating every second or third day, which is what the stereotypical high fat “keto” diets promote. If we are eating a high fat diet and regularly fasting for extended periods of time, it is the fasting itself that underlies body fat loss and lower insulin, not all the added dietary fat.

Eating tons of bacon, butter, cream and avocado makes perfect sense in a therapeutic diet for epilepsy, seizure disorder or as an adjunct treatment in glioblastoma or Alzheimer’s disease, because the goal is to produce lots of ketones — but if one wants to lose weight without using frequent periods of fasting, then adding tons of fat to food makes no sense. We want to utilize our fat stores for energy, not burn dietary fat.

One can use any one of a number of low carbohydrate approaches to accomplish weight loss, as well as improve blood sugar — by focusing on eating nutrient dense foods with a high protein-to-energy ratio, and that are rich in micronutrients.  Protein also increases satiety, helps build muscle and is much less calorically dense than fat [16].

Whether starting at a brief ketogenic level and working up (such as the method used by Protein Power, New Meal Revolution or Westman, Phinney and Volek’s approach in the New Atkins, or using an approach I often do which is to start people off at 130 g of carbohydrate per day, and lower carbohydrate as required to achieve clinical outcomes. In either approach, weight loss and lower insulin and glucose can be achieved without extended or frequent periods of fasting.

That doesn’t mean there aren’t benefits to doing short daily periods of fasting, such as from after dinner on one day until the first meal the following day — there are.  It simply isn’t required for weight loss.

Final Thoughts…

There are several therapeutic ketogenic diets that can be used in epilepsy and seizure disorder as well as other conditions, and other types of therapeutic ketogenic diets that are considered Medical Nutrition Therapy (MNT) for the treatment of type 2 diabetes and obesity.

The idea that there is “THE keto diet” which is high in fat is a fallacy — one that has the unintended consequence of many people failing to lose weight (and often gaining weight) because they don’t realize that it needs to be combined with periods of intermittent fasting.  A weight-loss “keto diet” that is 75% fat, 15% protein and 10% carbs is only ONE type of ketogenic diet. It is by no means “THE keto diet!”.  A diet that is low in carbohydrate and rich in nutrient-dense lean protein, as well as a wide range of vegetables and fruit is just as much a “keto diet” because it is low in carbohydrate — and one that can be used successfully to achieve weight loss, with no fasting required.

In short, there is no one-size-fits-all-low-carb or keto diet, but rather a range of low carb and keto diets that can be chosen from, based on each person’s personal preference, as well as their specific medical needs.

More Info?

If you would like more information about type of low carb or ketogenic diet that might be best suited to you, please send me a note using the Contact Me form on the tab above.

To your good health!

Joy

You can follow me on:

Twitter: https://twitter.com/JoyKiddie
Facebook: https://www.facebook.com/BetterByDesignNutrition/

References

  1. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13
  2. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  3. U.S. Department of Health and Human Services: Final MNT regulations. CMS-1169-FC. Federal Register, 1 November 2001. 42 CFR Parts 405, 410, 411, 414, and 415
  4. Peterman MG, The Ketogenic Diet, JAMA. 1928;90(18):1427—1429. doi:10.1001/jama.1928.02690450007003
  5. Kossoff EH, Doward JL. The Modified Atkins Diet. Epilepsia 2008; 49 (Suppl8): 37-41
  6. Evert, AB, Dennison M, Gardner CD, et al, Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report, Diabetes Care, Ahead of Print, published online April 18, 2019, https://doi.org/10.2337/dci19-0014
  7. Diabetes Canada, Diabetes Canada Position Statement on Low Carbohydrate
    Diets for Adults with Diabetes: A Rapid Review Canadian Journal of Diabetes (2020), doi: https://doi.org/10.1016/j.jcjd.2020.04.001.
  8. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
  9. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
  10. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
  11. Fung J (2016) Obesity Code, Greystone Books, Vancouver
  12. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
  13. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
  14. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
  15. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020)
  16. Paddon-Jones D, Westman E, Mattes RD et al, Protein, weight management, and satiety, The American Journal of Clinical Nutrition, Volume 87, Issue 5, May 2008, Pages 1558S—1561S, https://doi.org/10.1093/ajcn/87.5.1558S

Copyright ©2020 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.

 

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The Keto Diet — a potentially dangerous and an unhealthy diet

INTRODUCTION: I’ve heard other Dietitians say that the keto diet is a potentially dangerous and an overall unhealthy diet because it focuses on ‘high intakes of processed meat, butter and cream’. Some have said that harmful effects were seen as much as three years post keto —  with one case involving symptoms of uncontrollable food cravings and “a head rush” after ingesting any carbs, and another three cases of people having developed severe adverse health effects, including one with newly diagnosed diabetes that wasn’t present before the diet, and two others with non-alcoholic fatty liver disease. All of these individuals were said to have gained all the weight back plus more, and the concern was raised as to whether the keto diet can really be called “a key to diabetes reversal or diabetes remission” because we haven’t actually fixed a broken pancreas. This article will address some of these beliefs.

The belief that there is such as thing as “the keto diet” (singular) which is high in processed meat, butter and cream is common, but incorrect. More on that below.

As a Dietitian, I am expected to be well-informed about a wide range of dietary options and to speak and write from an evidenced-based perspective, but the reality is that as Dietitians we can’t be knowledgeable in all available diets. While I am by no means an expert on low carb or ketogenic diets, I have written over 200 articles on the topic (published on my dedicated low-carb practice website), and have been using low carb and ketogenic diets as two of several dietary options in clinical practice for the past 5 years.

Firstly, with regards to the severe adverse health effects that the 3 individuals reportedly developed as a result of following the keto diet, it has been documented that abnormal glucose responses are present as long as 20 years before a diagnosis of Type 2 Diabetes[1] and the American Association of Clinical Endocrinologists (AACE) concluded that both insulin resistance and prediabetes precede a diagnosis of type 2 diabetes[2] — which means that people presenting with type 2 diabetes after following “the keto diet” had been developing the disease for many years prior.

Furthermore, non-alcoholic fatty liver disease (NAFLD) is strongly associated with insulin resistance, which is characterized by excessive hepatic glucose production (high production of glucose by the liver) and compensatory hyperinsulinemia [3-9], which is the response of the liver to produce high amounts of insulin in order to remove the excess glucose. The association of NAFLD with insulin resistance indicates that the fatty liver was developing for years prior to these individuals following “the keto diet”.  Furthermore, it has been documented that a classic ketogenic diet (KD) is an effective treatment for nonalcoholic fatty liver disease [10] and “rapidly reverses NAFLD and insulin resistance despite increasing circulating non-esterified fatty acids, the main substrate for synthesis of intrahepatic triglycerides” [10].

As for “the keto diet” being a key to diabetes reversal or diabetes remission, I’ve addressed this in detail in a previous article.

So, let me address the misconception that there is such a thing as “the keto diet” (singular), which is high in processed meat, butter and cream.

Many Types of Keto Diets

There are a variety of therapeutic ketogenic diets, including the Ketogenic Diet (KD), the Modified Ketogenic Diet and the Modified Atkins Diet, as well as a variety of ketogenic diets that are used both for therapeutic reasons (such as the management of type 2 diabetes), as well as those that are followed for personal choice.

What makes a diet therapeutic is that it is used to treat a medical condition or conditions and is recommended by a Physician, and implemented by a Dietitian, or by the MD themselves. When a doctor sends me a referral to implement a Modified Atkins Diet for one of their patients with seizure disorder, it is a therapeutic diet. So is a referral to implement a very low carbohydrate / ketogenic diet for the treatment of type 2 diabetes or fatty liver disease.

Use of a very low carb / keto diet by Physicians or Dietitians in the management of type 2 diabetes should come as no surprise to anyone given that these dietary patterns are considered Medical Nutrition Therapy (MNT) in the treatment of type 2 diabetes.

The American Diabetes Association has stated that reducing carb intake has the most evidence for improving blood sugar and has included the use of a very low carbohydrate (ketogenic) eating pattern for treating type 2 diabetes as listed in their 2019 Consensus Report and both the 2019 Standards of Medical Care in Diabetes (2019) and Standards of Medical Care in Diabetes (2020).  In addition, Diabetes Canada released a Position Statement in April of this year outlining that a low carb and very low carb / keto (<50 g of carbohydrates per day) are both safe and effective treatment for adults with diabetes. 

Therapeutic ketogenic diets such as the classic Ketogenic Diet (KD), the Modified Ketogenic Diet and the Modified Atkins Diet are by necessity high fat diets — because the goal is to produce very high levels of ketones in order to improve clinical outcomes in epilepsy and seizure disorder, and as adjunct treatment in glioablastoma ( a type of brain cancer) and in Alzheimer’s disease.  The Ketogenic Diet (KD) has a 4:1 ratio i.e. 4 parts of fat for every 1 part protein and carbs, the Modified Ketogenic Diet (MKD) has a 3:1 ratio; 3 parts fat for every 1-part protein and carbs, and the Modified Atkins Diet (MAD) has a 2:1 ratio, with 2 parts fat for every 1-part protein and carbs.

What makes a weight loss diet ketogenic is not how much fat it contains, but the amount of carbohydrate it contains. Very low carbohydrate / ketogenic diets are diets where carbohydrate is limited to 20-50 g per day or 10% of total energy intake [11]. It is this low carbohydrate intake that results in the body using fat as its primary fuel, rather than carbohydrate.  At this level of carbohydrate intake, blood ketone levels increase at or above 0.5 mmol/L, resulting in ketosis. 

Ketosis is where betahydroxybutyrate (BHB) reaches levels between 0.5 – 3.0 mmol/L (and up to 4.0 mmol/L for therapeutic ketogenic diets such as those used in the treatment of epilepsy, seizure disorder and glialblastoma), whereas nutritional ketosis for optimal weight loss is commonly set with BHB levels between 1.5-3.0 mmol/L [12].

There is no one “keto diet” for weight loss but a range of choices, only some of which I will mention here.

I will start by looking at one of the earlier known diets that used a ketogenic level of carbohydrate intake; the 1972 Dr. Atkins’ Diet Revolution[13], by Dr. Robert Atkins. The so-called “Atkins’ Diet” had an introductory phase which limited carbohydrate intake to 20-25 grams of net carbs from nuts, seeds, and low carb vegetables, and this phase resulted in people going into ketosis.  In fact, this first phase of the Atkin’s Diet is what forms the basis for the Modified Atkins Diet, a therapeutic diet used in the treatment of epilepsy and seizure disorder.

The 1997 Protein Power[14] published by Dr. Micheal Eades, and his wife Dr. Mary Dan Eades is a low carb,  high protein, moderate fat ketogenic diet. In fact, the authors warn in the book that eating a large number of calories as fat would make it impossible to lose weight, so this is not a high fat diet at all.

The New Atkins For a New You [15], was redesigned in 2010 by Dr. Eric Westman, Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, and is a low carb high fat, moderate protein weight loss diet that has 4 phases, with the first phase being ketogenic to start with (20-50 g carbs per day), but is only ketogenic for two weeks.  In phase two, more carbohydrate is added as nuts & seeds, berries, cherries and melon, cheese,  dairy products, legumes (pulses), tomato juice and vegetable cocktail and this level is maintained until close to goal weight when phase 3, then phase 4 (both higher carb) are implemented.

The 2011 book by Dr. Stephen Phinney MD PhD, and Dr. Jeff Volek RD PhD, The Art and Science of Low Carbohydrate Living [16] is not a diet book, but elaborates on type 2 diabetes as ‘carbohydrate intolerance’ and on the importance of electrolyte and mineral management to avoid side effects of a ketogenic diet. In this approach, added dietary fat is incorporated after weight loss, for long term weight maintenance, to prevent further weight loss.

Then there is the 2013 Real Meal Revolution [17] by Tim Noakes, Sally-Ann Creed, Jonno Proudfoot which is a handbook on the Banting lifestyle (which originated in the late 1800s), with foods broken down into green list, orange list and red list, with varying levels of carbohydrate intake.

In 2016, Dr. Jason Fung, a Toronto nephrologist (kidney specialist) wrote the Obesity Code [18] which promotes a high fat version of a very low carb / keto diet, which is used in conjunction with his 2016 book written with Jimmy Moore titled The Complete Guide to Fasting [19]. In 2020, Fung published Life in the Fasting Lane [20], written with Eve Meyer and Megan Remos which builds on his approach of using a low carb high fat diet along with intermittent fasting.

In 2014, the web site “Diet Doctor” was launched by Dr. Andreas Eenfeld. This was initially mostly with articles translated from his Swedish site and later added content from a variety of other people, including Dr. Jason Fung, Dr. Eric Westman and Dr. Ted Naiman.  In 2017, Eenfeld wrote his own diet book titled Low Carb High Fat Food Revolution [21], which promoted a high fat version of a very low carb / ketogenic weight loss diet.  Later, Dr. Eric Westman went on to found his own Adapt weight loss program which is a very low carb / keto, moderate protein, moderate fat approach and Dr. Ted Naiman went on to write his P:E Diet [22] which promotes a low carb, high protein, low fat approach.

Of ketogenic weight-loss diets above, the only ones that promote a high fat intake with processed meat (bacon), butter and cream are Dr. Jason Fung’s approach and the “Diet Doctor” approach. These are not THE “keto diet” — but one type of ketogenic approach, amongst many.

Self Administered Diets

If an individual hears about a diet from friends, or reads about it online and implements it, and is unsuccessful at losing weight or at keeping it off, or has adverse side effects, is this a reflection of the diet itself or is it a problem inherent in self-administered diets?

Does it matter if the failed “diet” is a calorie-restricted diet, a ketogenic diet, a grapefruit diet or any other diet?

Self administered diets of any type may or may not be appropriate for an individual, because the person’s individual nutritional needs, risk factors, metabolic conditions, and medications are not factored in. Weight-loss failure is one issue, as are potential adverse side-effects.  For example, if a person decides to follow a very low-calorie diet, experiences hypoglycemia and falls and injures themselves, is this the fault of the diet itself, or their self-administration of a diet?  Likewise, if a person decides to follow a very low carbohydrate / ketogenic diet and has an adverse reaction because of some medications they are taking, is this the fault of the particular version of a ketogenic diet they are following?

All diets have potential benefits and risks and self-administered diets pose additional risks that simply haven’t been factored in — regardless what type of diet is chosen.

Failed Weight Loss

Studies show that the failure rate with weight-loss diets is high — often as much as 80 – 90%, and regain of weight is thought to possibly be higher because follow-up rates are very low, and weights are often self-reported either by phone or mail [23].

The fact that most people will gain most of the weight they lost while dieting back, and sometimes end up weighing more than before dieting is not disputed, and is irrespective of the type of diet followed.

Regardless of the dietary approach chosen, “dieting” is not the answer for sustained weight loss. If someone goes “on” a diet that means that at some point they will go “off” of it.  In my opinion, a lifestyle change is a preferred approach and what will work for one person long-term, may not work for another. That is why I say that there is no one-sized-fits-all diet.

Final Thoughts…

Low carb and very low carb / ketogenic diets are two approaches that can suit some, but not all people.  A Mediterranean Diet or a whole food plant based (vegetarian) diet may be better suited to others. 

The misconception that there is one “keto diet” that is high in fat, especially processed meat, butter and cream is simply incorrect. There are a range of ketogenic (keto) diets and even in a high fat ketogenic diet, the fat can come from avocado, nuts and seeds and olives.

A high fat versions of a keto diet may be appropriate and work well in some individuals when used with periods of intermittent fasting, such as OMAD (one meal a day). In my clinical experience, I have observed that high fat versions of a keto diet often result in weight stalls and even weight gain in peri- or post-menopausal women. Since I don’t recommend extended fasting > 24 hours in older adults due to the muscle-loss which can result from the fasting, combined with the muscle loss that is already associated with aging, I generally recommend a higher protein, lower added fat version in such cases. In any case, there are lots of ways to do a ketogenic weight-loss diet — which is ultimately about the total amount of carbohydrate in the diet, not the amount of fat.

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To your good health!

Joy

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References

  1. Sagesaka H, S.Y., Someya Y, et al, Type 2 Diabetes: When Does It Start? Journal of the Endocrine Society, 2018. 2(5): p. 476-484.
  2. American Association of Clinical Endocrinologists Announces Framework for Dysglycemia-Based Chronic Disease Care Model, November 28, 2018, AACE Online Newsroom, url: https://media.aace.com/press-release/american-association-clinical-endocrinologists-announces-frameworkdysglycemia-based-c
  3.  Fabbrini E., et al. , Alterations in adipose tissue and hepatic lipid kinetics in obese men and women with nonalcoholic fatty liver disease. Gastroenterology 134, 424—431 (2008). 
  4. Gastaldelli A., et al. , Relationship between hepatic/visceral fat and hepatic insulin resistance in nondiabetic and type 2 diabetic subjects. Gastroenterology 133, 496—506 (2007). 
  5. Korenblat K. M., Fabbrini E., Mohammed B. S., Klein S., Liver, muscle, and adipose tissue insulin action is directly related to intrahepatic triglyceride content in obese subjects. Gastroenterology 134, 1369—1375 (2008). 
  6. Kotronen A., Juurinen L., Tiikkainen M., Vehkavaara S., Yki-Jí¤rvinen H., Increased liver fat, impaired insulin clearance, and hepatic and adipose tissue insulin resistance in type 2 diabetes. Gastroenterology 135, 122—130 (2008).
  7. Bugianesi E., et al. , Insulin resistance in non-diabetic patients with non-alcoholic fatty liver disease: Sites and mechanisms. Diabetologia 48, 634—642 (2005).
  8. Seppí¤lí¤-Lindroos A., et al. , Fat accumulation in the liver is associated with defects in insulin suppression of glucose production and serum free fatty acids independent of obesity in normal men. J. Clin. Endocrinol. Metab. 87, 3023—3028 (2002).
  9. Ryysy L., et al. , Hepatic fat content and insulin action on free fatty acids and glucose metabolism rather than insulin absorption are associated with insulin requirements during insulin therapy in type 2 diabetic patients. Diabetes 49, 749—758 (2000). 
  10. Luukkonen PK, Dufour S, Lyu K, et al. Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease. Proc Natl Acad Sci U S A. 2020;117(13):7347-7354.
  11. Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1—13.
  12. Nasir H. Bhanpuri, Sarah J. Hallberg, Paul T. Williams et al, Cardiovascular disease risk factor responses to a type 2 diabetes care model including nutritional ketosis induced by sustained carbohydrate restriction at 1 year: an open label, non-randomized, controlled study, Cardiovascular Diabetology, 2018, 17(56)
  13. Atkins, R. C. (1972). Dr. Atkins’ diet revolution; the high calorie way to stay thin forever. New York: D. McKay Co.
  14. Eades M, Dan Eades M (1997), Protein Power: The High-Protein/Low-Carbohydrate Way to Lose Weight, Feel Fit, and Boost Your Health–in Just Weeks! Bantam; New edition edition (1 December 1997)
  15. Westman E, Phinney SD, Volek J, (2010) Diet for Shedding Weight and Feeling Great, Atria Books February 17, 2010)
  16. Phinney SD, Volek J, (2011), The Art and Science of Low Carbohydrate Living, Beyond Obesity LLC
  17. Noakes T, Creed S-A, Proudfoot J, et al, (2013)The Meal Real Revolution, Quivertree Publications
  18. Fung J (2016) Obesity Code, Greystone Books, Vancouver
  19. Fung J, Moore J (2016), The complete guide to fasting : heal your body through intermittent, alternate-day, and extended fasting, Victory Belt Publishing
  20. Fung J, Meyer E and Ramos M (2020), Life in the Fasting Lane: The Essential Guide to Making Intermittent Fasting Simple, Sustainable, and Enjoyable, Harper Wave
  21. Eenfeld A, Low Carb, High Fat Food Revolution: Advice and Recipes to Improve Your Health and Reduce Your Weight (2017), Skyhorse Publishers
  22. Naiman T, Shewfelt W,  The PE Diet: Leverage your biology to achieve optimal health (2020),
  23. Mann T, Tomiyama AJ, Westling E, Lew AM, Samuels B, Chatman J. Medicare’s search for effective obesity treatments: diets are not the answer. Am Psychol. 2007;62(3):220-233. doi:10.1037/0003-066X.62.3.220

 

Copyright ©2020 BetterByDesign Nutrition Ltd.

LEGAL NOTICE: The contents of this blog, including text, images and cited statistics as well as all other material contained here (the ”content”) are for information purposes only.  The content is not intended to be a substitute for professional advice, medical diagnosis and/or treatment and is not suitable for self-administration without the knowledge of your physician and regular monitoring by your physician. Do not disregard medical advice and always consult your physician with any questions you may have regarding a medical condition or before implementing anything  you have read or heard in our content.