Ketoacidosis, on the other hand, is dangerous. But it’s usually limited to people with type 1 diabetes, striking when their glucose levels rise due to illness or a missed insulin dose. Without insulin, cells can’t take in glucose, so they burn fat for fuel instead, producing exceptionally high ketone levels—much higher than the amount generated by the keto diet. That, in combination with high blood glucose levels, essentially poisons the blood. “It’s very easy to tell the difference between nutritional ketosis, which has no negative symptoms [aside from ‘keto breath,’ which can smell like nail polish remover], and dietary ketoacidosis, which is an illness that requires hospitalization and causes lethargy, abdominal pain, nausea, vomiting, rapid breathing, and lack of appetite,” says William Yancy, MD, program director at the Duke Diet and Fitness Center in Durham, North Carolina.
Recently, many of my patients have been asking about a ketogenic diet. Is a ketogenic diet safe? Would you recommend it? Despite the recent hype, a ketogenic diet is not something new. In medicine, we have been using it for almost 100 years to treat drug-resistant epilepsy, especially in children. In the 1970s, Dr. Atkins popularized his very-low-carbohydrate diet for weight loss that began with a very strict two-week ketogenic phase. Over the years, other fad diets incorporated a similar approach for weight loss.
Although many hypotheses have been put forward to explain how the ketogenic diet works, it remains a mystery. Disproven hypotheses include systemic acidosis (high levels of acid in the blood), electrolyte changes and hypoglycaemia (low blood glucose). Although many biochemical changes are known to occur in the brain of a patient on the ketogenic diet, it is not known which of these has an anticonvulsant effect. The lack of understanding in this area is similar to the situation with many anticonvulsant drugs.
A ketogenic diet is comprised of approximately 10% of daily calories coming from healthy carbohydrates such as leafy greens, nonstarchy vegetables, and limited amounts of legumes and berries; 20% of daily calories coming from proteins such as omega-3-rich fish and grass-fed animal protein; and ~70% of daily calories coming from high-quality fats such as avocado, unsaturated and medium-chain triglyceride oils, nuts and seeds, and coconut.
As I wrote in op-eds for the Wall Street Journal61 and Medscape,62 the Lancet Public Health study is based on very thin data. The questionnaire underlying the report left out questions regarding popular foods, such as pizza and energy bars, and did not consider alcohol consumption. Moreover, the “low-carb” diet group in this study included people eating up to 37% of calories as carbohydrates—not low-carb according to the latest science. Ultimately, this is the kind of data that can show association but not establish causation, which means it is the kind of data one can use to generate hypotheses but not prove them. This kind of data would never be considered sufficient to approve a drug, for instance. The same standards should be applied to diet. Quite a few researchers, including myself, had our critiques published in Lancet Public Health.63 The authors replied but did not respond to most of the criticisms.
In Asia, the normal diet includes rice and noodles as the main energy source, making their elimination difficult. Therefore, the MCT-oil form of the diet, which allows more carbohydrate, has proved useful. In India, religious beliefs commonly affect the diet: some patients are vegetarians, will not eat root vegetables or avoid beef. The Indian ketogenic diet is started without a fast due to cultural opposition towards fasting in children. The low-fat, high-carbohydrate nature of the normal Indian and Asian diet means that their ketogenic diets typically have a lower ketogenic ratio (1:1) than in America and Europe. However, they appear to be just as effective.
In 1921, Rollin Turner Woodyatt reviewed the research on diet and diabetes. He reported that three water-soluble compounds, β-hydroxybutyrate, acetoacetate, and acetone (known collectively as ketone bodies), were produced by the liver in otherwise healthy people when they were starved or if they consumed a very low-carbohydrate, high-fat diet. Dr. Russell Morse Wilder, at the Mayo Clinic, built on this research and coined the term "ketogenic diet" to describe a diet that produced a high level of ketone bodies in the blood (ketonemia) through an excess of fat and lack of carbohydrate. Wilder hoped to obtain the benefits of fasting in a dietary therapy that could be maintained indefinitely. His trial on a few epilepsy patients in 1921 was the first use of the ketogenic diet as a treatment for epilepsy.
Beyond just fat loss, ketosis has an additional benefit in that it spares muscle when you’re eating at a deficit. On a normal diet, when you eat fewer calories than you need for the day, your body breaks down muscle and fat in nearly equal amounts to make up for the difference. With keto, your body is primed to burn mostly fat, particularly if you’re meeting your protein goal for the day. This results in a better metabolism and more total fat lost. Low carb recipes offer:
When you eat less than 50 grams of carbs a day, your body eventually runs out of fuel (blood sugar) it can use quickly. This typically takes 3 to 4 days. Then you’ll start to break down protein and fat for energy, which can make you lose weight. This is called ketosis. It's important to note that the ketogenic diet is a short term diet that's focussed on weight loss rather than the pursuit of health benefits.
Despite its explosive popularity, there’s a lot of confusion about what the ketogenic (keto) diet really is. “Many people think they’re following a keto diet when they’re really just consuming a low-carbohydrate diet,” says Patti Urbanski, MEd, RD, CDE, a certified diabetes educator with St. Luke’s Hospital in Duluth, Minnesota. “So one person’s ‘keto diet’ may look very different than another’s.”
The ketogenic diet is calculated by a dietitian for each child. Age, weight, activity levels, culture, and food preferences all affect the meal plan. First, the energy requirements are set at 80–90% of the recommended daily amounts (RDA) for the child's age (the high-fat diet requires less energy to process than a typical high-carbohydrate diet). Highly active children or those with muscle spasticity require more food energy than this; immobile children require less. The ketogenic ratio of the diet compares the weight of fat to the combined weight of carbohydrate and protein. This is typically 4:1, but children who are younger than 18 months, older than 12 years, or who are obese may be started on a 3:1 ratio. Fat is energy-rich, with 9 kcal/g (38 kJ/g) compared to 4 kcal/g (17 kJ/g) for carbohydrate or protein, so portions on the ketogenic diet are smaller than normal. The quantity of fat in the diet can be calculated from the overall energy requirements and the chosen ketogenic ratio. Next, the protein levels are set to allow for growth and body maintenance, and are around 1 g protein for each kg of body weight. Lastly, the amount of carbohydrate is set according to what allowance is left while maintaining the chosen ratio. Any carbohydrate in medications or supplements must be subtracted from this allowance. The total daily amount of fat, protein, and carbohydrate is then evenly divided across the meals.
To lower your heart risks while following a keto diet, be mindful of the types of fats you’re eating. “Most nutritionists encourage people to get their fat from heart-healthy mono- and polyunsaturated fats,” Urbanski says. So even though going keto may sound like a license to load up on bacon and butter, reach for unsaturated fats from foods such as olives, nuts, seeds, and avocados, and olive, canola, and nut oils.
Because people with type 2 diabetes are at an increased risk for cardiovascular disease, there’s a specific concern that the saturated fat in the diet may drive up LDL, or “bad,” cholesterol levels, and further increase the odds of heart problems. If you have type 2 diabetes, talk to your doctor before attempting a ketogenic diet. They may recommend a different weight-loss diet for you, like a reduced-calorie diet, to manage diabetes. Those with epilepsy should also consult their doctor before using this as part of their treatment plan.