How does a nutritional keto supportive diet work?
You may remember that under normal circumstances, glucose is the primary source of fuel for the body. It is derived from a wide variety of carbohydrate sources such as sugars, fruits, starchy vegetables (i.e., sweet potatoes, potatoes, beets, carrots), dairy products (i.e., milk, yogurt, cheese, ice cream), refined/processed grains (i.e., wheat, corn, soy, rice) grounded into flour (i.e., bread). When simple carbohydrates are dramatically reduced or cut out of the diet, and replaced with only whole plant based foods, the body will revert to using the storage form of sugar called glycogen as its alternative source of fuel (Paoli, 2014; Iacovides & Meiring, 2018). Typically, there are approximately 600 grams of glycogen stored in the liver and skeletal muscles with this value changing based on a person’s diet, body mass, and activity level (Murray & Rosenbloom, 2018).
Once the glycogen stores dwindle in the liver, muscle, and blood, the body will undergo gluconeogenesis where sugar is made from substrates such as lactic acid, glycerol, and certain amino acids. This means that glucose is still being delivered to your tissues at all times, but the original source derived from breaking down carbohydrates has been changed to fat and certain amino acids. This is a natural process that occurs all the time.
Nutritional ketosis pushes this physiologic state a little bit further. When the body puts the brakes on glucose production, it finally shifts into ketogenesis within a few days. Fat is broken down into fatty acids which are further metabolized into ketone bodies (the smallest fraction of a fat molecule) in the liver.
When fat replaces carbohydrate as the primary macronutrient, the body can produce 15 times more energy than when burning simple sugars and other carbohydrates. Ketosis is a fundamental and gradual shift the body has to make in order to thrive.
How can you tell if your body is burning fat instead of carbohydrates?
The benefits of the ketogenic diet depend on the body actually achieving a state of ketosis and its ability to produce adequate cellular energy. This means the diet has to be tailored correctly.
Ketone bodies are removed via the urine, and hence, high levels of ketones measured in urine are one indication that the body is in a state of ketosis. Another indication of ketosis is “fruity breath” that happens as a result of acetone, a byproduct of ketone acetoacetate decarboxylation, eliminated through respiration (Paoli, 2014).
Who should follow a ketogenic diet?
In integrative medicine, we treat every individual as unique and, like all therapeutic diets, the keto diet may not be for everyone. However, research has demonstrated the benefits of the ketogenic diet for a myriad of health conditions. The hallmark examples are metabolic conditions such as obesity, diabetes, high cholesterol, and seizure disorders.
The ketogenic diet has been gaining popularity because it promotes weight loss. Research clearly demonstrates that the diet is an effective weight loss strategy. The ketogenic diet has also been incredibly successful in improving biomarkers of metabolic syndrome, insulin resistance, and type 2 diabetes in overweight individuals, with improvements in blood glucose regulation, insulin sensitivity, triglyceride levels, and HDL cholesterol levels (Masood & Uppaluri, 2018).
In a recent review on the use of the ketogenic diet in the treatment of obesity, obese individuals following a very low carbohydrate diet demonstrated improved glycemic control, hemoglobin A1c levels, and lipid markers, corroborating earlier studies. Those with insulin resistance also demonstrated improved markers of metabolic syndrome. Although the specific mechanism has yet to be illuminated, the authors proposed several possible explanations for these benefits including (Paoli, 2014):
In another study examining the effects of a long-term ketogenic diet in obese individuals, the plan was followed for 24 weeks, and participants followed a diet consisting of:
Results showed increases in HDL and decreases in total body weight, BMI, triglycerides, LDL cholesterol, and blood glucose. More importantly, with results like these (and those that came after it), the ketogenic diet demonstrates safety, indicating that it is all right to follow for longer periods of time without adverse side effects (Dashti et al., 2004).
Furthermore, in addition to the diet as a weight loss intervention, the ketogenic diet was originally developed in the 1920s to address pediatric epilepsy. As described above, the body undergoes ketogenesis as a result of severe carbohydrate restriction on the dietary plan, mimicking the effects of fasting. Over one hundred years ago, it was observed that fasting had protective, anti-seizure effects, which led to the implementation of the ketogenic diet (Barañano & Hartman, 2008).
In another assessment, one randomized controlled trial examined the effects of the diet in 145 children with treatment-intractable epilepsy (experiencing more than seven seizures per week). Seizure frequency measured after three months was significantly lower in the ketogenic diet group compared to the control group, supporting the use of the ketogenic diet as an effective lifestyle intervention (Neal et al., 2008).
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Barañano, K. W., & Hartman, A. L. (2008). The ketogenic diet: Uses in epilepsy and other neurologic illnesses. Current Treatment Options in Neurology, 10(6), 410-419.
Berg, J.M., Tymoczko, J.L., & Stryer, L. (2002). Biochemistry. 5th edition. New York: W H Freeman.
Dashti, H.M., Mathew, T.C., Hussein, T., Asfar, S.K., Behbahani, A., Khoursheed, M.A., Al-Sayer, H.M., Bo-Abbas, Y.Y., & Al-Zaid, N.S. (2004). Long-term effects of a ketogenic diet in obese patients. Experimental & Clinical Cardiology, 9(3), 200-205.
Iacovides, S., & Meiring, R. M. (2018). The effect of a ketogenic diet versus a high-carbohydrate, low-fat diet on sleep, cognition, thyroid function, and cardiovascular health independent of weight loss: Study protocol for a randomized controlled trial. Trials, 19(1).
Khakh, B. S., & Burnstock, G. (2009). The double life of ATP. Scientific American, 301(6), 84-92.
Lefevre, F., & Aronson, N. (2000). Ketogenic diet for the treatment of refractory epilepsy in children: A systematic review of efficacy. Pediatrics, 105(4).
Masood, W., & Uppaluri, K.R. (2018). Ketogenic diet. Treasure Island, FL: StatPearls Publishing.
Murray, B., & Rosenbloom, C. (2018). Fundamentals of glycogen metabolism for coaches and athletes. Nutrition Reviews, 76(4): 243–259.
Neal, E. G., Chaffe, H., Schwartz, R. H., Lawson, M. S., Edwards, N., Fitzsimmons, G., . . . Cross, J. H. (2008). The ketogenic diet for the treatment of childhood epilepsy: A randomised controlled trial. The Lancet Neurology, 7(6), 500-506.
Paoli, A. (2014). Ketogenic diet for obesity: Friend or foe? International Journal of Environmental Research and Public Health, 11(2), 2092-2107.