Early studies reported high success rates; in one study in 1925, 60% of patients became seizure-free, and another 35% of patients had a 50% reduction in seizure frequency. These studies generally examined a cohort of patients recently treated by the physician (a retrospective study) and selected patients who had successfully maintained the dietary restrictions. However, these studies are difficult to compare to modern trials. One reason is that these older trials suffered from selection bias, as they excluded patients who were unable to start or maintain the diet and thereby selected from patients who would generate better results. In an attempt to control for this bias, modern study design prefers a prospective cohort (the patients in the study are chosen before therapy begins) in which the results are presented for all patients regardless of whether they started or completed the treatment (known as intent-to-treat analysis).
After initiation, the child regularly visits the hospital outpatient clinic where they are seen by the dietitian and neurologist, and various tests and examinations are performed. These are held every three months for the first year and then every six months thereafter. Infants under one year old are seen more frequently, with the initial visit held after just two to four weeks. A period of minor adjustments is necessary to ensure consistent ketosis is maintained and to better adapt the meal plans to the patient. This fine-tuning is typically done over the telephone with the hospital dietitian and includes changing the number of calories, altering the ketogenic ratio, or adding some MCT or coconut oils to a classic diet. Urinary ketone levels are checked daily to detect whether ketosis has been achieved and to confirm that the patient is following the diet, though the level of ketones does not correlate with an anticonvulsant effect. This is performed using ketone test strips containing nitroprusside, which change colour from buff-pink to maroon in the presence of acetoacetate (one of the three ketone bodies).
In pediatric patients whose seizures could not be treated with these anti-epileptic drugs, a ketogenic diet was able to reduce seizures by more than 50% in 54% of the young patients tested, with 10% of the cohort becoming seizure-free after one year on the diet. Since this study, numerous additional studies have shown this modality to be effective for children and adults with epilepsy. Results of ketogenic diet–driven studies have included 55% of patients seeing a reduction in seizures by more than 50%, and 27% of patients seeing a 90% or greater reduction in seizures with many entering into complete remission.
The ketogenic diet has been studied in at least 14 rodent animal models of seizures. It is protective in many of these models and has a different protection profile than any known anticonvulsant. Conversely, fenofibrate, not used clinically as an antiepileptic, exhibits experimental anticonvulsant properties in adult rats comparable to the ketogenic diet. This, together with studies showing its efficacy in patients who have failed to achieve seizure control on half a dozen drugs, suggests a unique mechanism of action.
Keto for Alzheimer’s Disease: One characteristic of Alzheimer’s disease is insulin resistance in the brain (hence why it’s now being referred to as type III diabetes), which robs this critical tissue of energy. Limiting glucose while introducing ketones may be an effective mechanism for replenishing the energy in the tissue. The higher level of ketone production accompanied with a ketogenic diet is another example as to why this diet is superior to one that simply restricts carbohydrate intake. Additionally, Alzheimer’s disease is characterized by beta-amyloid deposition, which may also be mitigated by the implementation of a ketogenic diet.
Supplemental ketosis: This form of ketosis has recently gained momentum in the field of ketogenic dieting. Supplemental ketosis is a ketogenic state that is achieved through the ingestion of ketogenic supplements. Consuming these substances alone does not mean that an individual is “keto-adapted.” While these products can help during the keto-adaptation period, especially if one is experiencing the “keto-flu,” they will only elicit short-term increases in blood ketone levels. Exogenous ketones can acutely produce benefits similar to the ketogenic diet; however, these products are best used in conjunction with a well-formulated keto diet for beginners, or the very at least, a diet that restricts carbohydrates. The commonly used supplements on the market are medium-chain triglyceride (MCT) oil and exogenous ketones. MCT oil is a fat that, in contrast to other longer-chain fatty acids, travels straight from the intestines to the liver where it is readily metabolized. This allows for ketone production in the liver to occur faster than with other fats (long-chain fatty acids have to travel through the lymph and circulatory systems first). Exogenous ketones are synthetic substances that mimic the ketones produced in our body (endogenous ketones). Exogenous ketones can come in the form of ketone salts or ketone esters.
H. Guldbrand, B. Dizdar, B. Bunjaku, T. Lindström, M. Bachrach-Lindström, M. Fredrikson, C. J. Östgren, F. H. Nystrom, “In Type 2 Diabetes, Randomisation to Advice to Follow a Low-carbohydrate Diet Transiently Improves Glycaemic Control Compared with Advice to Follow a Low-fat Diet Producing a Similar Weight Loss,” Diabetologia (2012) 55: 2118. http://link.springer.com/article/10.1007/s00125-012-2567-4.
A: The amount of weight you lose is entirely dependent on you. Obviously adding exercise to your regimen will speed up your weight loss. Cutting out things that are common “stall” causes is also a good thing. Artificial sweeteners, dairy, wheat products and by-products (wheat gluten, wheat flours, and anything with an identifiable wheat product in it).
“The cleaner, the better when it comes to the keto diet,” says Jadin. Focus on “whole” and “unprocessed.” Also, strive for a mix of saturated and unsaturated fats for balance. Note: Tipping the scale toward too much protein is a common pitfall many people make on the keto diet. Mind your protein intake, since too much can kick you out of ketosis, says Jadin.
Everyone has to find their nutritional sweet spot for producing enough ketones and staying in ketosis, but “the core principle of the diet is to keep carbohydrate intake low enough, so your body continues producing ketones at elevated levels,” says Volek. “Your body adapts to this alternative fuel and becomes very efficient at breaking down and burning fat.”
One area where food tracking can be especially helpful, though, is ensuring that you're hitting the right ratios of macronutrients-protein, carbs, and fat. "The most researched version of the ketogenic diet derives 70 percent of calories from healthy fats, 20 percent from protein, and only 10 percent from carbs," explains Charles Passler, D.C., nutritionist, and founder of Pure Change. "In the ideal world, each keto meal and snack should have that same (70/20/10) ratio of macronutrients, but studies have shown that you'll still achieve great results even if each meal varies slightly from that ratio, just as long as you don't exceed 50 grams per day of carbs, or eat those carbs in one sitting," says Passler. In order to achieve these ratios without a preset meal plan from a dietitian or doctor, some food tracking is probably going to be necessary. But once you get the hang of things, you may not need it anymore.
When dietary carbohydrate is broken down into the energy substrate glucose, thereby raising blood glucose levels, the pancreas is stimulated to secrete insulin (the hormone that stores fat and inhibits ketone production). However, when carbohydrate intake is restricted, insulin remains suppressed, and the body’s primary fuel source shifts from glucose to fat, priming the body to enter a state of ketosis. When fat oxidation/breakdown is increased to a certain extent, ketones are made in the liver through a process known as ketogenesis (i.e., keto + genesis = ketone formation). When carbohydrate intake is restricted, blood glucose and insulin levels decrease, which allows fat stores to be broken down rapidly for energy. Most cells in the body can utilize either fatty acids or ketones for fuel, including the brain, which has shown to be more efficient in the presence of ketones rather than glucose.
Detrimentally, this results in high levels of both ketones and glucose. Extremely high ketone levels in the blood will elicit a dangerous biological environment that can even result in death. It must be clarified that DKA is very different than nutritional ketosis or fasting ketosis; ketone levels cannot be produced at such high levels in healthy individuals as they are with those in DKA.
Bonnie J. Brehm, Randy J. Seeley, Stephen R. Daniels, and David A. D’Alessio, “A Randomized Trial Comparing a Very Low Carbohydrate Diet and a Calorie-Restricted Low Fat Diet on Body Weight and Cardiovascular Risk Factors in Healthy Women,” The Journal of Clinical Endocrinology & Metabolism: Vol 88, No 4; January 14, 2009. http://press.endocrine.org/doi/full/10.1210/jc.2002-021480.
Understanding which foods to eat may seem like the most difficult and time-consuming task for most individuals adopting a keto diet for beginners. However, you will soon realize that many of your favorite foods can still be enjoyed without the carbohydrate load. To start, it should be noted that it is critical to eliminate sugar or any fast-digesting carbohydrates. These include, but are not limited to: cookies, chocolate, cakes, crackers, ice cream, cereal, pretzels, pastries, baked goods, fruit juice, soft drinks, honey, candy, chips, bread, and white potatoes. However, there are ways to still enjoy some of these foods as long as they are prepared differently by using ketogenic-friendly ingredients. Check here for more recipes and try these tips:
A whopping 46 percent of American adults still eat what’s considered a “poor” diet in American Heart Association standards, notes a study published in June 2016 in JAMA, which was based on a survey of nearly 34,000 people. (5) For some people, going on a keto diet is an effort to change those poor habits, but there’s the risk of falling back into your old ways once the diet is over. Don’t go straight back to a standard American diet, because you’ll likely lose any health benefits and regain the weight.
There exists great debate on how to quantify the macronutrient ratios and percentages for a traditional ketogenic diet. Despite numerous opinions, the common and ultimate objective is to develop a diet that is sustainable in achieving the desired outcome (i.e., a state of ketosis). As such, while it is suggested that 65–80% of the total calories come from fat, and 15–30% from protein, these numbers will be optimized according to every individual’s unique metabolic needs. For example, an individual who is trying to achieve a state of ketosis might have a different ratio of macronutrient requirements than someone who is using a ketogenic diet to improve their body composition. Once the body begins to use fat as its primary fuel source, metabolic “keto-adaptation” characterized by increased production of ketones takes place. It is important to note that there is no “optimal” level of ketosis, nor is there a standard macronutrient profile to achieve a ketogenic state, because factors such as activity level, body composition, and desired health and performance outcomes will influence these variables. Although individualized, Ketogenic.com currently offers a Keto Calculator that can help provide you with a starting point on your macronutrients.
A systematic review in 2018 looked at 16 studies on the ketogenic diet in adults. It concluded that the treatment was becoming more popular for that group of patients, that the efficacy in adults was similar to children, the side effects relatively mild. However, many patients gave up with the diet, for various reasons, and the quality of evidence was inferior to studies on children. Health issues include high levels of low-density lipoprotein, high total cholesterol, and weight loss.
The ketone bodies are possibly anticonvulsant; in animal models, acetoacetate and acetone protect against seizures. The ketogenic diet results in adaptive changes to brain energy metabolism that increase the energy reserves; ketone bodies are a more efficient fuel than glucose, and the number of mitochondria is increased. This may help the neurons to remain stable in the face of increased energy demand during a seizure, and may confer a neuroprotective effect.
Keto for Cancer: Cancer is now being discussed as primarily a metabolic disease in which glucose can fuel its progression. Due to recent light shed on this subject, intensive investigations are underway and have begun to reveal that restricting carbohydrate intake can slow oncogenesis and that a full ketogenic-state may elicit even greater therapeutic benefits. Furthermore, research also suggests that fasting and the state of ketosis may increase the sensitivity of cancer cells to radiation and chemotherapy.
“Combining a super restrictive diet with long periods of non-eating is not good,” says Keatley. “The body will cannibalize its own muscle for energy if intake from food is too low but the body does not differentiate between something like a calf muscle or a heart muscle. Keep in mind all your important organs are made of smooth muscle and going on a diet like this may harm something like your bladder or lungs just as much as provide fat loss.”
You’re transitioning. Your body is equipped to process a high intake of carbs and a lower intake of fat. Your body needs to create enzymes to be able to do this. In the transitional period, the brain may run low on energy which can lead to grogginess, nausea, and headaches. If you’re having a large problem with this, you can choose to reduce carb intake gradually.
Kristin Parker is an American temporarily living in South Korea. Her role with Team Diet Doctor is customer service. If you have a question or a comment on our social media platforms, website or our Facebook group, she will likely be the one to answer you back! Kristin cooks for a family of four, including two hungry teenage sons. Her keto meal plan yields generous servings of substantial, hearty meals that they all like.
Also make sure that you know what foods have mostly carbs, fat, and protein, so you can make the right choices. For instance, it’s not just bread, pasta, chips, cookies, candy, and ice cream that contain carbs. Beans may contain protein, but they’re also very high in carbohydrates. Fruit and veggies also mostly contain carbs. The only foods that don’t contain carbs are meat (protein) and pure fats, like butter and oils (including olive oil and coconut oil).