The Keto Diet

I attended the Obesity Medicine Association medical conference in Washington, D.C., and had the pleasure of listening to Andreas Eenfeldt, MD, present on the Keto diet. This article represents a summary of his comments on Ketogenic Diets (a.k.a. “The Keto Diet.”) in addition to my own analysis.

While ketogenic diets are nothing new, lately there has been renewed interest in this weight loss approach. The Atkins diet was an early version of this. Generally, people can eat protein (meat, chicken, fish, etc.) and fats (nuts, bacon, eggs, avocados, olive oil, etc.), but minimize eating of carbohydrates like breads, grains and fruits.

The U.S. dietary guidelines suggested to avoid fat back in the mid-1980’s. Since then, obesity rates in the United States have tripled. According to Dr. Eenfeldt, now there is a shift back towards eating fats, and several publications have shown that saturated fat intake does not increase risk of heart disease as was previously thought. (Note, Trans-fats are known to increase heart disease risk).

When a person stops eating carbohydrates, the muscles can process fat, but the brain needs a fuel source. In the absence of glucose, fat breakdown leads to ketone bodies. These can cross the blood brain barrier and the brain is able to use the ketone bodies as an energy source. In fact when in a state of ketosis, once adapted people feel very well. The measurable presence of these ketone bodies is where this diet got its name – the Keto Diet (short for ketogenic).

Many studies comparing low-carb to low-fat diets have demonstrated greater weight loss with low-carb; however, compliance is a significant issue in many of these trials. If a person loses weight on a keto diet but stops doing it, there will be weight regain. So, like other types of diets, if a person wants to use keto to lose weight, but then goes back to the previous style of eating, any additional weight loss from keto will not be sustained.

Dr. Eenfeldt states that there are 6 common side effects:

• “Keto flu” (day 2-5): Headache, lethargy, irritability. Cure: water and salt.
• Leg cramps: due to early loss of minerals. Cure: water, salt, possibly magnesium
• Constipation: due to dehydration, possibly from less fiber. Cure: water, salt, fiber, if needed, milk of magnesia.
• Bad breath: from ketones transforming into acetone, often temporary but not always. Breath freshener can help, or eat a little more carbohydrates to reduce ketosis.
• Heart palpitations: due to dehydration or stress hormones to maintain glucose levels during the initial week. Usually temporary, treat with water and salt.
• Reduced physical performance: temporary as muscles adapt to burning fat for energy. Recommend caution with physical activity first couple of weeks. Important: water and salt. Targeted carbs  before competitions may help.

Another possible side effect is elevated cholesterol, but per Dr. Eenfeldt, this generally does not occur. He states that the average rise in LDL cholesterol is 6 points. However, there is often a big improvement in HDL and triglycerides. But some get very high LDL cholesterol – often young, lean, very active people. If this happens, avoid “bulletproof coffee” (coffee plus butter or coconut oil) and eat  less saturated fat, more olive oil, try intermittent fasting, or, if needed, add more carbs and less fat.

Can keto diets shorten life? An article published in August 2018 suggested that low carb diets may shorten life up to 4 years. This article was written based on a food frequency questionnaire from the 80’s with one follow-up years later. Similar to a rebuttal published in Wall Street Journal, Dr. Eenfeldt feels this observational study was not well done, along with many other nutritional epidemiological studies. He states that “You can prove anything about anything.”

Dr. Eenfeldt states that benefits of the “Keto Diet” may include weight loss, reversal of type 2 diabetes, cessation of seizures, improvement in irritable bowel syndrome, and improvement in polycystic ovarian syndrome.  He further states you don’t need to take any ketone supplements, MCT (medium chain triglyceride) supplements, etc. There is no good evidence for these supplements, in his opinion.

So, what do I think? We have used ketogenic diets successfully at CNC for decades, ranging from our old “Nutrifast” program to our current “Modified Fast” Program. In the 90’s there were studies showing that these programs offered superior weight loss to other dietary styles. However, in 2005, a large review published by Dr. Tom Wadden out of the University of Pennsylvania showed that although there may be  better weight loss in the short-term, they were not superior long-term.

15 years of treating patients affected by obesity has taught me an important lesson – there is no “One-Size Fits-All” approach. Some of my most successful patients that I have worked with started with a Modified Fast and managed to sustain a weight loss of 100 pounds or more. But an equal number of successes started with a full meal replacement Optifast program – which is non-ketogenic. More and more, I have seen greater success with a non-ketogenic Optifast™ program rather than a ketogenic program. Further, I am not sure if remaining in a state of ketosis permanently is the best thing for one’s health.

So, if a ketogenic diet works well for you, great! Consider working with a CNC dietitian on our Modified Fast. Ketosis not your thing? No worries – consider any of the other options. Whichever option helps you keep weight off, be healthy and feel good is the best choice for you.