Tag Archive for: ketogenic diet

It’s Still All About the Calories

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The keto vs. Mediterranean diet study was interesting for a variety of reasons. The researchers deserve a lot of credit for even attempting to try a study of this magnitude; 40 subjects may not seem like a lot, but to provide food via delivery together with instructions on preparation is very expensive and labor intensive. It should be noted that a portion of the study took place during the lockdown phase of COVID-19; that delayed some testing, but to their credit, the subjects affected continued the particular diet they were on for the two weeks until testing could be scheduled. Here are my thoughts on the results.

Blood Lipids

  • Subjects on the keto diet showed a greater decrease in triglycerides (TG) than those on the Mediterranean diet.
  • On the other hand, those on the Mediterranean showed a greater decrease in LDL-cholesterol than did the keto diet subjects.

While the researchers discussed it at length, I don’t think it was relevant. All subjects began with average fasting TG in the normal range. While both diets decreased TG, that the keto diet reduced it slightly more isn’t earth shattering when you start at a normal reading.

The same holds true for the LDL-cholesterol. Yes, the Mediterranean diet reduced it while the keto diet increased it, but the net was 6 mg/dl over the initial readings. What could have been concluded was that neither diet reduced LDL-cholesterol by an amount that was clinically meaningful.

The Microbiome

There were no tests of the changes in the microbiome under each diet reported—at least not yet. Subjects had a definite decline in fiber intake, especially when they provided their own food in the keto diet. The Mediterranean diet saw an increase in fiber intake when subjects provided their own food.

Why mention this at all? The microbiome controls the initial processing of nutrients. In addition, the immune function begins in the gut. While the keto diet may have provided some benefit related to HbA1c, at what cost? We simply don’t know. What we do know based on other research is that the lack of fiber changes the probiotic content of the microbiome.

The Bottom Line

The data showed that the subjects averaged 200 to 300 fewer calories per day regardless of diet and maintained the reduction over both diets. They ate better, they ate less, and they lost weight.

I think this study was important because it leaves us with better questions to ask in the future, such as: how would health measures be affected if subjects reduced calories another way? It also proves what I’ve been saying for years. The average weight loss after the study was 13 to 17 pounds, and that was maintained during the follow-up period. This was not a weight loss study, yet regardless of the initial diet, the subjects lost weight. I’ve said it before and I’ll say it again: regardless of the type of diet, it’s still all about the calories.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN doi.org/10.1093/ajcn/nqac154

Face-Off: Mediterranean vs. Keto

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Last week ended with the publication of an interesting study on two popular diets, Mediterranean and ketogenic, and their potential benefits for people with elevated HbA1c levels; HbA1c is a blood test that measures your average blood sugar levels over the past three months. I use the word “diet” as a description of the type of foods eaten, not as a weight loss program.

The researchers constructed what they termed the Well-Formulated Ketogenic Diet plan to compare with a Mediterranean diet. Both approaches reduced sugar, refined carbohydrates, and starchy vegetables; the Mediterranean diet added unprocessed whole grains, beans, and fruit. The subjects had either prediabetes or type 2 diabetes. The primary goal of the 36-week program was to monitor changes in HbA1c along with a variety of secondary measures including blood lipids.

The 40 subjects were randomly assigned to using the keto diet for 12 weeks and then switching to the Mediterranean diet for 12 weeks or vice versa. Food was delivered to all subjects for the first four weeks of both phases, which I think is brilliant—one of the hardest parts of learning a new way of eating is discovering how the foods can be combined and prepared, along with getting used to the different tastes. After those four weeks, they provided their own food that fit within the particular diet they were on at the time. The final 12 weeks were left up to the subjects.

The results demonstrated both dietary approaches reduced HbA1c about the same amount, and the decrease was maintained regardless of which diet they began with. However, there were some differences as well. I’ll give you those on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: AJCN doi.org/10.1093/ajcn/nqac154

Review: That Sugar Film

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Summer gives us a chance catch to up on reading or binge watch a television series, so I thought I’d watch some of the nutrition documentaries that I’ve been asked about. I’ve done some in the past such as Forks Over Knives. It gives me a chance to check the facts on what’s said and how true or relevant it is. That’s the case with the film titled That Sugar Film. It was written, directed, and starred in by an Australian filmmaker Damon Gambeau. Hugh Jackson even performed the opening scene.

The premise of the movie is that all sugar is bad. There was at least one anti-sugar and ketogenic diet proponent in Gary Taubes author of Good Calories, Bad Calories. The filmmaker also assembled a team of experts who were going to provide information and medical supervision during an experiment he wanted to conduct on himself. The experiment was to see how a high-sugar diet, one typical of the average Australian, would impact him. Based on what he claimed to eat, he was somewhere between the paleo diet and the ketogenic diet before that.

There was the requisite discussion of the cholesterol hypothesis and how fat was chosen as the demon to avoid instead of sugar as they relate to heart disease. The sugar industry conspiracy was also talked about in the same vein as the tobacco industry. But it’s what he did to himself that was by far the most interesting: switching to a diet that contained 40 teaspoons of sugar a day for 60 days. What happened to him? That’s coming on Thursday.

What are you prepared to do today?

        Dr. Chet

Can Medium-Chain Triglycerides Help with Alzheimer’s Disease?

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Medium-chain triglycerides are hot today. Derived from coconut oil or palm oil, they have the advantage of being used for energy without much processing by the liver. People doing the ketogenic diet use them, as well as athletes looking for more energy. From a medical perspective, MCTs are used for people with fat-absorption problems and to treat epilepsy in some people. For today, I’ll focus on the use of MCTs for preventing and treating Alzheimer’s disease.

From an examination of the research on those two specific areas, the research is sparse. There’s little to no research that MCTs will prevent Alzheimer’s disease. There are a couple of small studies that have been done to treat Alzheimer’s patients with coconut oil or MCTs, but the results are equivocal.

The reason MCTs may benefit the brain is energy production via a non-sugar-based pathway. Whether additional energy for the brain helps learning and memory is unknown. What seems clear is that prediabetes and type 2 diabetes contributes to the development of Alzheimer’s, so it seems more important to lower refined carbohydrates and eat a more plant-based diet. I think including extra virgin coconut oil in a better diet could be helpful. At this point, specific MCT products seem unwarranted due to the lack of research. They may prove to be useful for some groups based on genetics, phenotype, and microbiome. Just not yet.

What are you prepared to do today?

        Dr. Chet

References:

1. Lancet Neurol. 2018 Jan;17(1):84-93. doi: 10.1016/S1474-4422(17)30408-8.
2. Am J Alzheimers Dis Other Demen. 2014 Aug;29(5):409-14. doi: 10.1177/1533317513518650.

Dealing with Keto Breath and Other Odors

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Quick question: what side effect do you typically assign to eating asparagus? I bet you took less than a second to come up an answer: a different odor to your urine, sometimes quite pungent. Asparagus is a cruciferous vegetable with phytonutrients that produce the effect.

On Tuesday and Thursday, we looked at digestive problems with going keto; today we’ll look at odor issues.

Ketosis, the result of metabolizing fat into ketones for use as a fuel, also has a specific odor associated with it: your breath can smell like nail polish remover. The ketones may have complicated names such as acetoacetate, beta-hydroxybutyrate, and acetone, but they do one thing: they cause an odor in your mouth and as you breathe out. Our bodies always make those odors, but because we’re forcing the body to produce more ketones, the odor is more noticeable as ketone remnants exit the body via breath and urine.

In this case, there’s no real solution. If you want to use fat as a fuel almost exclusively, you learn to live with the smell. Just make sure to drink plenty of water, because water is important to get rid of these chemicals and protect the kidneys. Drinking water and brushing more frequently may help compensate for keto breath.

Health news has recently become full of eye-catching headlines about something termed “keto crotch.” While it can affect men, it seems to especially impact women by changing the odor of the vagina and vaginal discharges. It seems obvious that it’s the result of the diet, although there’s no research that I could find that has examined it. Gynecologists speculate that it’s the change in the vaginal pH that can contribute to increased odors. If that’s true, it would radically change the vaginal microbiome and that could change the odor. At this point, we don’t know.

One thing that may help is taking probiotics that contain Lactobacilli strains; some research has demonstrated benefits for bacterial vaginosis. Whether probiotics will help with the odor associated with the keto diet or not is unknown, but it’s possible. A prebiotic would also be needed to feed the probiotic because on a keto diet, there’s no fruit with its special sugar to feed the bacteria.

The Bottom Line

Going keto has side effects. Some people may not get any of them. Genetics, the microbiome, and other factors no doubt will have an impact on the extent of the side-effects. I’ve tried to cover the obvious ones this week but there are others, from depression to fatigue.

Which brings me to a question I’m often asked: what do I think about the ketogenic diet? I think it’s a good tool to use fat as a fuel for a limited time, and together with the right exercise program, it can be effective in helping people lose body fat; that’s why it’s part of the Fat-Burning Plan in the Optimal Performance Program.

I assess diets this way: what has to be added to make it healthy? Veganism requires most people get vitamin B12 from somewhere other than meat. The keto diet lacks vitamins, minerals, fiber, and probiotics typically found in vegetables. Both diets lack essential nutrients. If you decide to go keto, it’s important to add these supplements to your diet: a multivitamin-multimineral, probiotics, prebiotics, and fiber.

Because of the side effects, I just don’t think going keto is sustainable. Use it as a tool, as a means to an end for a specific goal. The goal is to stay healthy by learning to always do these three things: Eat better. Eat less. Move more.

What are you prepared to do today?

        Dr. Chet

Keto: Clearing the Air and Your Colon

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The next keto diet issues are still related to the digestive system: excessive gas and constipation. Let’s address the issue of gas first so that maybe the next time you bend over, you won’t have to worry about challenging the strength of your anal sphincter muscles.

The protein content of the revised keto diet may be lower than prior versions, but the body still has to break it down. If you don’t make enough digestive enzymes to breakdown the protein, it produces gas as it ferments in the microbiome. A lot of it. The simplest thing to do may be take a digestive enzyme that contains proteases to breakdown proteins before every meal. Taking a probiotic may also be a good idea, but we don’t know the specific strains of bacteria that will work on protein.

On the other hand, probiotics in general may help ease the constipation that can occur while on the ketogenic diet. The problem is this: the colon doesn’t have enough to do—waste products from foods are simply not there. Fats don’t have anything left after digestion; almost all protein sources don’t have much residue either. But your digestive system still has to repair and rebuild the digestive system on a regular basis. In addition to the probiotics, soluble fiber may again be the solution for the same reason as with diarrhea: it adds bulk to the stool.

I’ll wrap this up on Saturday with the topic that seems to still be making headlines: the odors associated with going keto.

What are you prepared to do today?

        Dr. Chet

The Downsides of Going Keto

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News stories about the side-effects of the still-popular ketogenic diet are showing up more frequently, so let’s review those this week and look at what you can do to address the issues while still attempting to stay in ketosis.

The first side effect is generally diarrhea. With the newer version of the ketogenic diets, the emphasis is on fats and oils, which make up the majority of calories, with protein second, and carbs last. Two things seem to contribute to diarrhea. The first is the use of fats containing high amounts of medium-chain triglycerides (MCT) such as extra-virgin coconut oil and other oil products made with added MCT. The reasons are unknown; it’s most likely related to changes in the microbiome due to the radical change in diet, but it may be that it’s a question of volume of MCT. Oils such as olive oil don’t seem to cause the problem. The solution to this problem may be experimenting with different oils to find the ones that work better for each individual.

The other reason the keto diet can cause diarrhea is a lack of fiber. The keto eating plan has no significant source of fiber in a diet without grains, beans and legumes, and vegetables; a couple cups of lettuce aren’t going to help very much. Soluble dietary fiber supplements may help, whether psyllium, inulin, or other fiber sources. Begin slowly by adding 5 grams a day mixed with water and slowly increase it to 15 or 20 grams spread out over the day. It can add bulk to the stool and stop what has been described as explosive diarrhea.

More on Thursday. Tomorrow is the Insider Conference call. There’s time for you to join before tomorrow’s call at 9 p.m. Eastern Time. What are you prepared to do today?

        Dr. Chet

Top Nutrition Trends for 2019

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After the fitness trends I wrote about Tuesday, I thought I would see if there were any other surveys by nutritionists or dieticians on nutrition or diet trends. Turns out that The Pollack Communications in conjunction with Today’s Dietician just did their 7th Annual What’s Trending in Nutrition survey of registered dieticians. Not surprising to me is that the ketogenic diet ranked number one with intermittent fasting close behind. I get questions about those all the time.

We are alive today because our ancestors survived. While that seems obvious, it also means something else. Before we developed the ability to grow crops and animals, we relied on hunting and gathering. It also means our ancestors had to survive periods of famine when crops were poor and animals were scare. That type of survival resulted in genes that were efficient in storing fat. Today there’s no real famine in modern countries. In fact, quite the opposite; food is abundant. It’s not surprising people are growing—we’re the heaviest we’ve ever been.

Many blame processed foods or refined carbohydrates or artificial sweeteners or food additives or something else for the obesity epidemic. It’s not that complicated: we simply eat too much. Sure, quality counts, but eating 4,000 calories a day will still have the health effects of eating 4,000 calories a day.

Fasting has a role to play in helping us have the energy we need to perform our best exactly when we need it. So does the ketogenic diet. Both will be topics in the 9th Annual Super Bowl Webinar this Sunday at noon. Find out how to use both to your advantage by signing up today. Members and Insiders: log in to drchet.com before registering to make sure you get your discount.

What are you prepared to do today?

        Dr. Chet

Reference: Pollock Communications; Today’s Dietitian.