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COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS

January 22, 2020

Ketogenic Diet: Risks, Benefits and Alternatives

Moderator: Lisa Diewald, MS, RD, LDNProgram Manager MacDonald Center for Obesity Prevention and EducationM. Louise Fitzpatrick College of Nursing

Nursing Education Continuing Education Programming Research

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OBJECTIVES

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1. Provide an overview of the ketogenic diet, including the risks and benefits

2. Review the latest evidence on the effectiveness of the ketogenic diet in treating obesity and type 2 diabetes.

3. Discuss clinical and practical implications and future research directions

CE DETAILS

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation

Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration

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NUTRITION FUTURE FORWARD: ARE WE READY FOR OUT OF THE

BOX THINKING?

March 6, 2020 9 AM-4 PM

Driscoll Hall AuditoriumVillanova University

RNs: 6 contact hoursRD/RDN/DTR: 6 CPEUs

Villanova.edu/cope

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CE CREDITS

• This webinar awards 1 contact hour for nurses and 1 CPEU for dietitians

• Suggested CDR Learning Need Codes:

4000, 5370, 5790, 9020

• Level 2

• CDR Performance Indicators: 6.2.5, 6.3.7, 6.3.8

Nursing Education Continuing Education Programming Research

Ketogenic Diet: Risks, Benefits and Alternatives

Shivam Joshi, MDClinical Assistant Professor of MedicineNYU School of Medicine

DISCLOSURE

The planners and presenter of this program have no conflicts of interest to disclose.

Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity.

Ketogenic Diet: Risks, Benefits, and Alternatives

Shivam Joshi, MD

Clinical Assistant Professor

NYU School of Medicine

January 22, 2020

Disclosures

• None

• But, I do eat carbohydrates.

Table of Contents

• Basics of the Ketogenic Diet

• Benefits• The Ketogenic Diet for Weight Loss

• The Ketogenic Diet for Type 2 Diabetes Mellitus

• Potential Risks of the Ketogenic Diet• Pediatric Epilepsy Literature

• LDL Cholesterol

• Kidney Stones

• Conclusion

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The Origins of the Ketogenic Diet

• The ketogenic diet actually first emerged as a treatment for epilepsy

• Since the time of Hippocrates, people have noticed that fasting suppressed seizure activity

• Trials of fasting confirmed this in the 1900s

• In 1921, Dr. Russell Wilder of the Mayo Clinic thought the benefit of fasting was actually the ketones produced during fasting

The Origins of the Ketogenic Diet

• Ketones can also be produced by restricting carbohydrates

• Dr. Wilder then used high-fat, low-carb ketone-inducing diet to produce similar seizure-reducing effects in pediatric patients with epilepsy

• Ketogenic diets for epilepsy were popular until the use of anti-epileptic drugs (beginning with phenytoin in 1938)

• Ketogenic diets later re-emerged in the 20th century as a treatment for obesity and diabetes in the context of the popular low-carbohydrate trend

The Basics of the Ketogenic Diet

• The ketogenic diet is a very-lowcarbohydrate diet

• To replace carbohydrates, fat is consumed as the primary source of calories

• Protein is consumed in “moderation”

Very Low Carbohydrate Diet

Up to 5 to 10% carbohydrates

(20 to 50 grams of carbs per day)

Low Carbohydrate Diet

Up to 20% carbohydrates

How much is 20 to 50 grams of carbs per day?

20 grams of carbs• 0.8 medium apple OR

• 0.7 medium banana OR

• 1.4 slices of whole wheat bread

50 grams of carbs• 2 medium apples OR

• 1.87 medium bananas OR

• 3.57 slices of whole wheat bread

The keto diet is an extreme version of a low-carbohydrate diet

What are ketones?

• Ketones produced during the oxidation of fat

• Keto diet, DKA, alcoholism, starvation (anytime there is a shortage of usable carbohydrates)

• Fats are oxidized in the liver to ketones

• Oxidation of fatty acids yields ATP for energy

• Ketones are also used for energy

Acetoacetate

Beta-hydroxybutyrate

Acetone

Keto Diet Ratio

Ratio

- Describes the intensity of the carbohydrate restriction

- Example: 4:1 ratio means 4 grams of fat to 1 gram of protein and carbohydrates combined

- Higher the ratio the more intense the carbohydrate restriction

- Popular ketogenic diets are 4:1 or 3:1

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What does the keto diet look like?

Keto Diet for Weight Loss

Background on Obesity

• Adults obese: 39.8%

• Adults overweight or obese: 71.6%

• In years past, America’s solution to the obesity epidemic: low-fat diets

Low-Fat Foods from Before

The Problems with Those Low-Fat Diets

Problem 1• Many foods – although low in fat

– still were not healthy!

Problem 2• These foods simply exchanged

calories from fat with calories from refined carbohydrates

Serdula et al. AJPH 2004 94(6):2014.

The Problems with Those Low-Fat Diets

Problem 3• A “low-fat diet” is a diet that is

typically less than 10 to 30% of calories from fat

• America never ate less than 30% of calories from fat (we were never truly on a low-fat diet!)

Ford et al. AJCN 97.4 (2013): 848.

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The Problems with Those Low-Fat Diets

Problem 4• We are eating between 240 to 802

more calories per day than we did ~50 years ago!

Increasing Caloric Consumption

Ford et al. AJCN 97.4 (2013): 848FAOSTAThttps://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/

Low-Fat Diets Low-Carb Diets

Popular Logic“If restricting fat and eating more

carbs made things worse, then doing the opposite should fix

things.”

In Reality1. We never ate healthy foods!

2. We ate a lot of refined carbs!

3. We never truly were on a low-fat diet!

4. We actually ate more calories!

Low-carbohydrate diets

Keto Diet for Weight Loss

• Keto enthusiasts tout the diet as an effective means of weight loss

• Increased metabolism

• Increased satiety

• Increased compliance

• Less calories consumed

Keto Diet for Weight Loss

• Numerous anecdotal experiences that are often highly publicized

However, caloric restriction by any means will result in weight loss!

Caloric Restriction for Weight Loss: Take 1

• RCT of 160 participants randomly assigned to either Atkins, Weight Watchers, Zone, or Ornish Diet

• No difference in weight loss between strategies at one year

“Amount of weight loss was associated with self reported

dietary adherence level (r=0.60; P<.001) but not with diet type

(r=0.07; P=.40).”

Caloric Restriction for Weight Loss: Take 2

• RCT of 811 overweight assigned to 1 of 4 diets of different macronutrient compositions

• After two years, weight loss was essentially the same on all diets

“CONCLUSIONS

Reduced-calorie diets result in clinically meaningful weight loss regardless of

which macronutrients they emphasize.”

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Caloric Restriction for Weight Loss: Take 3

• RCT of 609 participants assigned to either a LOW-FAT or a LOW-CARBOHYDRATE diet for 12 months

• No significant difference in weights between the two groups at 12 months

Caloric Restriction for Weight Loss: Take 4

• Meta-analysis of 53 studies and 68,128 people

But What about Fat Loss and Energy Expenditure?

• Meta-Analysis of 32 controlled feeding studies

• Both energy expenditure and fat loss are higher on low fat diets

But what about ketogenic diets for weight loss?

• Meta-analysis of randomized controlled trials lasting for more than 12 months

• 13 studies involving 1,415 individuals

• Ketogenic diet showed an additional weight loss of 0.91 kg (1.98 lbs) over low-fat diets

• Statistically significant but is it clinically significant?

Dietary adherence is important for weight loss, but this diet is very hard to adhere to…

So much so that nearly every long-term (>12 months) study reporting carb intake at the end was not actually on a keto diet

Bueno et al.Br J N 2013110(7): 1178

Some of the Weight Lost is Not Fat….

Water Loss Fat Free (Lean Body) Mass Loss

Kirkpatrick et al. Journal of Clinical Lipidology. 2019;13:689,711.

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Fat Free Mass Loss Greater on a Ketogenic Diet

• 17 overweight men on a conventional diet or a ketogenic diet

• Both diets lost fat

• But loss of fat-free mass (muscle mass) was greater with the keto diet

Hall KD et al. Am J Clin Nutr. 2016;104:324-333.

Keto Diet for Diabetes

Popular Understanding

• Since the ketogenic diet is low in carbohydrates, the idea is that blood sugars will not increase if there is no dietary glucose to increase it

• This is a good idea in theory, and has been used by some with type 1 diabetes

However…..

• Adherence is difficult

• Underlying glucose tolerance (insulin resistance in T2DM) may worsen

• Not any better than other dietary strategies

Promise with Industry-Funded, Non-Randomized Studies

• 1.3% improvement in HbA1c in those on the ketogenic diet

• Non-randomized

• Compared to “usual care” (unequal arms)

• Industry funded

RCTs Show Decreasing Benefit with Increasing Duration of Study

• Benefit decreases with duration of RCT

• Diabetes usually is not a short-term disease process for patients

Trial Duration Mean Reduction of HbA1c

on Ketogenic

Diet

Mean Reduction of HbA1c on Control

Diet

Difference in Mean HbA1c

Reduction Between

Diets

Westman et al. 2008

24 weeks 1.5% 0.5% 1.0%

Saslow et al. 2017

32 weeks 0.8% 0.3% 0.5%

Saslow et al. 2017

52 weeks 0.5% 0.2% 0.3%

Westman EC et al. Nutrition & Metabolism. 2008;5(1):36.Saslow LR et al. Journal of Medical Internet Research. 2017;19(2):e36.Saslow LR et al. Nutrition & Diabetes 7.12 (2017): 304

No Difference in Long-Term (> 1 year) Studies

• Meta-analysis of randomized controlled trials lasting for more than 12 months

• 8 studies involving 770 individuals (not all studies examined had data)

• No difference in fasting blood glucose or HbA1c between groups

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Fat Worsens Glucose Metabolism

• 15 male students divided into 3 groups to consume either carbohydrates, fats, or protein

• Each group consumed a high amount of their respective macronutrient for 2 days prior to a glucose tolerance test (175 g)

Sweeney. JAMA 1927

High-Fat Diets May Actually Worsen Glucose Metabolism

• Nine healthy young men (mean age 27 years; mean BMI 22 kg/m2) consumed either

• a normal diet (67% carbs, 22% fat, 11% protein) for 3 days

• LC/HFD (20% carbs, 69% fat, 11% protein) for 3 days

Numao et al. European Journal of Clinical Nutrition (2012) 66, 926–931

Despite eating fewer carbs, those on a high-fat diet had higher blood sugars!

The Ketogenic Diet May Actually Worsen Glucose Metabolism

• 17 men (BMI 25 to 30) were either fed a

• Basal diet (15% protein, 50% carbs, 35% fat) for 4 weeks

• Ketogenic diet (15% protein, 5% carbs, 80% fat) for 4 weeks

• Participants on both diets were then given a carb-rich meal

Rosenbaum et al. Obesity 27.6 (2019): 971-981 Post-prandial blood glucose was actually higher in those who had been on the ketogenic diet for the prior 4 weeks!

Side Effects of the Ketogenic Diet from the Pediatric Epilepsy Literature

No Shortage of Complications

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Vitamin & Mineral Deficiencies Deaths Associated with the Ketogenic Diet

Other Concerns of the Ketogenic Diet

Significant Increase in LDL Cholesterol & Apolipoprotein B

Raggi et al. Atherosclerosis (2020) 292:119-126

Apolipoprotein B also increases on the ketogenic diet and “should be taken as an ominous harbinger”

The Reason LDL Goes Up

• LDL increased by diets high in

• Saturated fat

• Trans fat

• Cholesterol

• Animal protein

• Triglycerides do go down (but likely do not outweigh the harm caused by an increase in LDL and apolipoprotein B)

• Utilizing polyunsaturated (PUFA) and monounsaturated (MUFA) fatty acids can help mitigate the rise in LDL (“plant keto”)

Kirkpatrick et al. Journal of Clinical Lipidology. 2019;13:689,711.

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Kidney Stones are a Common Complication of Ketogenic Diets

Reasons for Kidney Stones on the Ketogenic Diet

• Reduced water intake (fewer water containing fruits and vegetables)

• Animal protein acidifies the urine

• High fat consumption binds calcium in the gut (leading to oxalate excretion in in the urine)

• Low levels of dietary citrate (stone inhibitor)

• Low levels of dietary magnesium and potassium (stone inhibitors)

• Acidosis from the diet and foods acidifies urine (promotes stones)

• Salt content of these foods promotes urine calcium excretion

Anecdotes of Kidney Stones…

https://blog.virtahealth.com/ketogenic-diet-kidney-stones/

Other Potential Risks & Considerations

• Additional risks from low-carb diets in general

• Increased mortality

• Cardiovascular disease

• Birth defects?

• Unfavorable changes in the gut microbiome

• No long-term safety data exist• For example, what if this eating pattern

leads to increased CAD after 5 years? (we simply don’t know…)

• Opportunity cost of not eating whole grains, fruits, and legumes

• Lose out on potential health benefits of these foods

• Do we increase long-term risk?

• Unnatural eating pattern

• No known population to eat this way

• Even the Inuit have a mutation to circumvent ketosis

Concluding Thoughts

Risks, Benefits and Alternatives …

• Benefits: nearly non-existent when compared to a high-carb, low-fat dietary eating pattern (for most) after 1 year

• Risks: numerous from the pediatric epilepsy and low-carbohydrate literature; opportunity costs; lack of long-term safety data

• Alternatives: numerous alternatives exist with wide variations even within carbohydrate-rich diets

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Diets are a Personal Choicebut Require Informed Decision Making

Also, there are a lot of other diets out there!

Benefits

Risks

US News & World Report Rankings

At the top… At the bottom…

For More Information … “An ounce of prevention…”

Acknowledgments

• Dr. Rob Ostfeld, Montefiore Health System

• Dr. Michelle McMacken, NYU School of Medicine

• Dr. David Goldfarb, NYU School of Medicine

• Dr. James Underberg, NYU School of Medicine

• Dr. William Bulsiewicz, MD, MSCI

• Brenda Davis, RD

Thank You!How to Reach Me

• Website: www.afternoonrounds.com

• Email: afternoonrounds@gmail.com

• Facebook/Instagram/Twitter: sjoshiMD

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QUESTIONS & ANSWERS

Moderator: Lisa K. Diewald MS, RD, LDNEmail: cope@villanova.eduWebsite: www.villanova.edu/COPE

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