From butter coffee popping up on local coffee shop menus, to bacon- covered everything, I think it’s safe to say that a Keto craze has hit! Perhaps you’ve seen individual stories of men or women starting a keto diet and losing a ton of weight, or their chronic conditions resolving, or their energy and focus and athletic performance skyrocketing! Intriguing, right?
While the internet can make it seem as though a Keto diet is the new magic approach to healing all that ails us, ketogenesis as a healing mechanism is not new… in fact is VERY, VERY old, perhaps even Biblical (1)!
But the ketogenic approach I am referencing began as something much different than we think of it today; it began via therapeutic fasting. Utilizing fasting to heal illness within the body is referenced as a healing modality in Hippocratic texts (cite)! As we look at various cultural and religious practices across history, we see that many, if not most of them, include a dedicated time of fasting!
However, long-term fasting is pretty intense, as far as therapeutic interventions go, and most often must be supervised by a healthcare team. The body needs fuel to survive, and it will do some pretty nasty things to keep that train rolling- like breaking down our muscle tissue for fuel- yes, our body will literally start eating itself if we don’t provide a fuel source.
So the conundrum of healthcare practitioners in our history was this: how can we attain the benefits (primarily the reduced and even completely eliminated occurrence of seizures) of fasting in a way that is sustainable, long-term?
Enter the 1921 research paper of Dr. Rollin Woodyatt, who discovered that the same byproducts we can see in fasting or starvation- beta hydroxybutyric acid, acetic acid, and acetone (collectively known as Ketone Bodies), can also be seen in diets that contain “too low a proportion of carbohydrate and too high a proportion of fat” (1). Another practitioner, Dr. Widler took this information and ran with it - or more accurately- began to experiment with it in pediatric epileptic patients at the Mayo Clinic.
Side note: One of the challenge points of understanding the benefits of the ketogenic diet is macronutrient ratios. While broadly, it is described as a diet in which a high proportion of daily calories come from fat sources, minimal amounts from carbohydrate, and moderate amounts of protein, the exact ratios set out in the research vary. Our responses to carbohydrate quantity vary greatly, as do our responses to individual sources of carbohydrate (e.g., one person may tolerate sweet potato well but not mango, while another may tolerate lentils well, but not white potato!).
However, the original “ketogenic diet” consisted of 1 kg/pound of body weight, 10-15 g of carbohydrate, and the rest of calories being consumed in the form of dietary fat, most often via Long Chain Fatty Acid sources. (1). And in looking at the research and clinical accounts of applying this dietary intervention in epileptic patients, it appears to be a very potent intervention (2, 3). Seizure episodes were significantly reduced in severity and frequency, and some eliminated altogether. This was true even in samples whose epilepsy had been resistant to medication. And so this form of intervention continued to be explored and applied throughout the first half of the 20th century. Despite its efficacy, the ketogenic diet, applied in this way with these patients does not come without side effects, some of which include: gastrointestinal distress, mineral deficiencies, stunted growth, osteopenia, increased bruising, increased risk of infection, decreased cardiovascular health, and even death (3). I feel it important to note that this rather rigorous and perhaps risky intervention continued to be used because other methods had not proven effective in the samples studied.
On a lighter note, it was discovered in the 1960’s that the inclusion of Medium Chain Fatty Acids (e.g., MCT oil) more readily produced ketones in the body and as a result, patients were able to increase the amount of protein that they consumed as well as experienced greater flexibility with carbohydrates while their bodies remained in a ketogenic state (4). In more modern renditions, this is often why it is recommended when applying a ketogenic diet to include MCT oil or exogenous ketones as part of the approach.
As time went on, new anticonvulsant medications came onto the scene that had more widespread application with epileptic patients, and so the ketogenic diet as an intervention began to have less utility. It wasn’t until the 1990’s when a prominent Hollywood producer shared the story of his son’s medication resistant epilepsy, and his astounding success with the ketogenic diet, which eliminated all seizure activity and allowed normal growth and development to continue (1), that clinical interest in the ketogenic diet as a therapeutic intervention was revived.
It was also around this time that the Atkin’s Diet became a popular approach to weight loss and metabolic regulation. Since that time, much research has been conducted on a low-carb, ketogenic diet as an approach to weight loss, metabolic regulation, and cardiovascular health (2, 3). (I’d like to add that there are burgeoning fields of research exploring the therapeutic application of a ketogenic diet for many neurological disorders, cognitive decline, mood disorders, cancer, and PCOS, too; [see 2]). And it appears that, at least initially, especially in samples labeled “overweight/obese” (as measured by Body Mass Index) that a low-carbohydrate ketogenic diet was able to produce weight loss, fat loss, reduced fasting blood glucose and hemoglobin A1c, and improved blood lipid markers (2,3); although in some cases glucose tolerance was reduced and results were variable (3).
So, is the state of ketogenesis magical? Does it have unique properties that melt weight and fat away?
First, let me explain, albeit briefly and simply, what happens in the body when we eat food, and (beyond fasting) how a ketogenic state is produced in our bodies:
I hope from this you can see that physiological ketosis is actually a naturally produced state in the body; a built-in backup mechanism to keep us alive in times of food/fuel scarcity. It can be an intentional dietary intervention, yes, but it can also be induced in everyday situations such as during sleep (in some individuals), and after a period of intensive exercise (if glycogen stores are depleted) (5).
But just because we can use ketones as fuel, does it mean we should...keep our bodies in ketosis...perpetually?
Ultimately it comes down to considering your health goals and what works best for you. For managing a debilitating chronic health condition, like medication-resistant epilepsy, keeping the body in ketosis may be a more long-term endeavor that requires medical supervision. For general health and the desire to shed 10 or 15 pounds, it may not be necessary, and may even induce some unintended negative consequences (e.g., beyond the brain and red blood cells, glucose is required to convert thyroid hormone into its active form). Even experts who advocate a ketogenic approach suggest that there are many individual considerations that will determine if and how it can support you. For example, Leanne Vogel, author of The Keto Diet: The Complete Guide to a High Fat Diet, describes how when she tried to apply a ketogenic diet as classically described, she would engage in binge episodes; however, she found that these binges actually lead to improvements in body composition, leading her to incorporate what she calls “carb-ups”: meals where dietary carbohydrates are increased and dietary fat decreased (6). She shares that she has found that with women in particular, as well as those who are dealing with thyroid and other hormone imbalances, adrenal fatigue, stress, anxiety, and menstrual irregularities, and weight loss plateaus, incorporating some carbohydrate may be beneficial (6). How much, and what kind is also a journey of self-discovery, and if you are intent on keeping the body in a ketogenic state for therapeutic or other reasons, testing via a blood ketone glucose meter maybe a helpful resource in determining this, at least initially.
While I support individuals becoming educated on the ever-changing health trends, and remaining an active participant in their health care journey, I also see the contagion of fads and the desire for one thing to fix everything. And for most people, a ketogenic diet, and in fact, no diet, is that one magic pill.
Personally, I the view of author of The Primal Blueprint, Mark Sisson, who says, “ketosis isn’t magic- it doesn’t melt away body fat. Instead, it works for many of the same reasons a standard low-carb Primal way of eating works: by reducing insulin, increasing mobilization of stored body fat, and decreasing appetite” (5). In fact, he discusses the idea of finding a zone, or a range of carbohydrate that works best for you as an individual, a range that can vary greatly (e.g. from 20-120 g of daily carbohydrate, and for some, even more). He also says that (of course in “healthy” individuals), once our bodies are off of the blood sugar rollercoaster commonly seen in the Standard American Diet, by getting back to eating a variety of properly prepared whole foods, we can probably relax a little and just trust our bodies! When you’re craving more carbohydrates, eat them (and you’re body will use the glucose efficiently)! When you’re not, don’t ! When you are physically hungry, eat! When you’re not, don’t (and your body will use ketones)! Feels pretty...simple, right? It can be! Of course, it isn’t always. But when focusing on general health, energy, and vitality, eating whole foods prepared in a way that you enjoy and listening to your body can go a LONG way, in conjunction with proper rest, movement, stress coping strategies, and support systems. As ancestral diets from across the globe show us, health is dependent upon so much more than macronutrient ratios, which by the way vary widely, and include both high fat and high carb approaches (7)!
This topic is, like many that spark controversy, big and complex. It is my hope that you come away feeling a bit more informed, and empowered to make the choices that will serve YOUR best health.
Your partner in health advocacy,
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1. Wheless, J.W. (2004). History and Origin of the Ketogenic Diet. In C.E. Safstrom and J.M. Rho (Eds.), Epilepsy and the Ketogenic Diet (pp. 31-50). Totowa, NJ: Humana Press.
2. Paoli, A., Rubini, A., Volek, J.S., & Grimaldi, K.S. (2013). Beyond weight loss: a review of the therapeutic uses of a very low-carbohydrate-(ketogenic) diets. European Journal of Clinical Nutrition, 67(8), 789-796. doi: 10.1038/ejcn.2013.116
3. Ballantyne, S., Ph.D., & Minger, D. (2015). Ketogenic diet literature review. Retrieved from: https://www.thepaleomom.com/wp-content/uploads/2015/05/Ketogenic-Diet-Literature-Review.pdf
4. Huttenlocher, P.R., M.D., Wilbourn, A.J., M.D., & Signore, J.M., B.S. (1971). Medium-chain triglycerides as therapy for intractable childhood epilepsy. Neurology, 21(11). doi: https://doi.org/10.1212/WNL.21.11.1097
5. Sisson, M. (June 7, 2017). The Definitive Guide to Keto. Mark’s Daily Apple. Retrieved from: https://www.marksdailyapple.com/the-definitive-guide-to-keto/
6. Vogel, L. (2017). The Keto Diet: The Complete Guide to A High-Fat Diet. Las Vegas, NV: Victory Bell Publishing Inc.
7. Kresser, C. (April 10, 2018). Why Quality Trumps Quantity When it Comes to Diet. Retrieved from: https://chriskresser.com/why-quality-trumps-quantity-when-it-comes-to-diet/
***All of the information provided here is intended for informational purposes only; please consult with your health support team before making any diet and lifestyle changes.