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| The Keto Diet Is Gaining Popularity, But Is It Safe? |
Finding yourself confused by the seemingly endless promotion of weight-loss strategies and diet plans? In this series, we take a look at some popular diets—and review the research behind them.
What is it?
The ketogenic or “keto” diet is a low-carbohydrate, fat-rich eating
plan that has been used for centuries to treat specific medical
conditions. In the 19th century, the ketogenic diet was
commonly used to help control diabetes. In 1920 it was introduced as an
effective treatment for epilepsy in children in whom medication was
ineffective. The ketogenic diet has also been tested and used in closely
monitored settings for cancer, diabetes, polycystic ovary syndrome, and
Alzheimer’s disease.
However, this diet is gaining considerable attention as a potential
weight-loss strategy due to the low-carb diet craze, which started in
the 1970s with the Atkins diet (a very low-carbohydrate, high-protein
diet, which was a commercial success and popularized low-carb diets to a
new level). Today, other low-carb diets including the Paleo, South
Beach, and Dukan diets are all high in protein but moderate in fat. In
contrast, the ketogenic diet is distinctive for its exceptionally
high-fat content, typically 70% to 80%, though with only a moderate
intake of protein.
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How It Works
The premise of the ketogenic diet for weight loss is that if you
deprive the body of glucose—the main source of energy for all cells in
the body, which is obtained by eating carbohydrate foods—an alternative
fuel called ketones is produced from stored fat (thus, the term
“keto”-genic). The brain demands the most glucose in a steady supply,
about 120 grams daily, because it cannot store glucose. During fasting,
or when very little carbohydrate is eaten, the body first pulls stored
glucose from the liver and temporarily breaks down muscle to release
glucose. If this continues for 3-4 days and stored glucose is fully
depleted, blood levels of a hormone called insulin decrease, and the
body begins to use fat as its primary fuel. The liver produces ketone
bodies from fat, which can be used in the absence of glucose.
When ketone bodies accumulate in the blood, this is called ketosis.
Healthy individuals naturally experience mild ketosis during periods of
fasting (e.g., sleeping overnight) and very strenuous exercise.
Proponents of the ketogenic diet state that if the diet is carefully
followed, blood levels of ketones should not reach a harmful level
(known as “ketoacidosis”) as the brain will use ketones for fuel, and
healthy individuals will typically produce enough insulin to prevent
excessive ketones from forming. How soon ketosis happens and the
number of ketone bodies that accumulate in the blood is variable from
person to person and depends on factors such as body fat percentage and
resting metabolic rate.
Excessive
ketone bodies can produce a dangerously toxic level of acid in the
blood, called ketoacidosis. During ketoacidosis, the kidneys begin to
excrete ketone bodies along with body water in the urine, causing some
fluid-related weight loss. Ketoacidosis most often occurs in individuals
with type 1 diabetes because they do not produce insulin, a hormone
that prevents the overproduction of ketones. However in a few rare
cases, ketoacidosis has been reported to occur in nondiabetic
individuals following a prolonged very low carbohydrate diet. [4,5]
The Diet
There is not one “standard” ketogenic diet with a specific ratio of macronutrients (carbohydrates, protein, fat).
The ketogenic diet typically reduces total carbohydrate intake to less
than 50 grams a day—less than the amount found in a medium plain
bagel—and can be as low as 20 grams a day. Generally, popular ketogenic
resources suggest an average of 70-80% fat from total daily calories,
5-10% carbohydrate, and 10-20% protein. For a 2000-calorie diet, this
translates to about 165 grams fat, 40 grams carbohydrate, and 75 grams
protein. The protein amount on the ketogenic diet is kept moderate in
comparison with other low-carb high-protein diets, because eating too
much protein can prevent ketosis. The amino acids in protein can be
converted to glucose, so a ketogenic diet specifies enough protein to
preserve lean body mass including muscle, but that will still cause
ketosis.
Many versions of ketogenic diets exist, but all ban carb-rich foods.
Some of these foods may be obvious: starches from both refined and whole grains
like breads, cereals, pasta, rice, and cookies; potatoes, corn, and
other starchy vegetables; and fruit juices. Some that may not be so
obvious are beans, legumes, and most fruits. Most ketogenic plans allow foods high in saturated fat, such as fatty cuts of meat, processed meats, lard, and butter, as well as sources of unsaturated fats,
such as nuts, seeds, avocados, plant oils, and oily fish. Depending on
your source of information, ketogenic food lists may vary and even
conflict.
The following is a summary of foods generally permitted on the diet:
Programs suggest following a ketogenic diet until the desired amount
of weight is lost. When this is achieved, to prevent weight regain one
may follow the diet for a few days a week or a few weeks each month,
interchanged with other days allowing a higher carbohydrate intake.
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The Research So Far
The ketogenic diet has been shown to produce beneficial metabolic
changes in the short-term. Along with weight loss, health parameters
associated with carrying excess weight have improved, such as insulin
resistance, high blood pressure, and elevated cholesterol and
triglycerides. [2,7] There is also growing interest in the use of
low-carbohydrate diets, including the ketogenic diet, for type 2
diabetes. Several theories exist as to why the ketogenic diet promotes
weight loss, though they have not been consistently shown in research:
A satiating effect with decreased food cravings due to the high-fat content of the diet.
A decrease in appetite-stimulating hormones, such as insulin and ghrelin, when eating restricted amounts of carbohydrate.
A direct hunger-reducing role of ketone bodies—the body’s main fuel source on the diet.
Increased calorie expenditure due to the metabolic effects of converting fat and protein to glucose.
Promotion of fat loss versus lean body mass, partly due to decreased insulin levels.
The following is a summary of research findings:
Potential Pitfalls
Following a very high-fat diet may be challenging to maintain.
Possible symptoms of extreme carbohydrate restriction that may last days
to weeks include hunger, fatigue, low mood, irritability, constipation,
headaches, and brain “fog.” Though these uncomfortable feelings may
subside, staying satisfied with the limited variety of foods available
and being restricted from otherwise enjoyable foods like a crunchy apple
or creamy sweet potato may present new challenges.
Some negative side effects of a long-term ketogenic diet have been
suggested, including increased risk of kidney stones and osteoporosis,
and increased blood levels of uric acid (a risk factor for gout).
Possible nutrient deficiencies may arise if a variety of recommended
foods on the ketogenic diet are not included. It is important to not
solely focus on eating high-fat foods, but to include a daily variety of
the allowed meats, fish, vegetables, fruits, nuts, and seeds to ensure
adequate intakes of fiber, B vitamins, and minerals (iron, magnesium,
zinc)—nutrients typically found in foods like whole grains that are
restricted from the diet. Because whole food groups are excluded,
assistance from a registered dietitian may be beneficial in creating a
ketogenic diet that minimizes nutrient deficiencies.
Unanswered Questions
What are the long-term (one year or longer) effects of, and are there any safety issues related to, the ketogenic diet?
Do the diet’s health benefits extend to higher risk individuals with
multiple health conditions and the elderly? For which disease
conditions do the benefits of the diet outweigh the risks?
As fat is the primary energy source, is there a long-term impact on
health from consuming different types of fats (saturated vs.
unsaturated) included in a ketogenic diet?
Is the high fat, moderate protein intake on a ketogenic diet safe
for disease conditions that interfere with normal protein and fat
metabolism, such as kidney and liver diseases?
Is a ketogenic diet too restrictive for periods of rapid growth or
requiring increased nutrients, such as during pregnancy, while
breastfeeding, or during childhood/adolescent years?
Bottom Line
Available research on the ketogenic diet for weight loss is still
limited. Most of the studies so far have had a small number of
participants, were short-term (12 weeks or less), and did not include
control groups. A ketogenic diet has been shown to provide short-term
benefits in some people including weight loss and improvements in total
cholesterol, blood sugar, and blood pressure. However, these effects
after one year when compared with the effects of conventional weight
loss diets are not significantly different.
Eliminating several food groups and the potential for unpleasant
symptoms may make compliance difficult. An emphasis on foods high in saturated fat also
counters recommendations from the Dietary Guidelines for Americans and
the American Heart Association and may have adverse effects on blood LDL
cholesterol. However, it is possible to modify the diet to emphasize
foods low in saturated fat such as olive oil, avocado, nuts, seeds, and
fatty fish.
A ketogenic diet may be an option for some people who have had
difficulty losing weight with other methods. The exact ratio of fat,
carbohydrate, and protein that is needed to achieve health benefits will
vary among individuals due to their genetic makeup and body
composition. Therefore, if one chooses to start a ketogenic diet, it is
recommended to consult with one’s physician and a dietitian to closely
monitor any biochemical changes after starting the regimen, and to
create a meal plan that is tailored to one’s existing health conditions
and to prevent nutritional deficiencies or other health complications. A
dietitian may also provide guidance on reintroducing carbohydrates once
weight loss is achieved.
A modified carbohydrate diet following the Healthy Eating Plate model may produce adequate health benefits and weight reduction in the general population.
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