Keto Diet: the good, the bad, and the ugly

So, what do you think about the keto diet?
I get asked this a lot in practice. The keto diet is certainly popular right now; almost everyone has heard of it, tried it, or followed an Instagram or blog page dedicated to it. Is the keto diet worthy of all of this hype? Does the keto diet work? Is the keto diet just another fad diet? These are all questions that come up regularly in practice. I try to have a very holistic approach with my patients; I like to ask them about their eating habits and exercise routines, simply because these topics matter when it comes to health. While studying for my Masters in Applied Clinical Nutrition, I realized so many illnesses and ailments could be controlled or at the very least helped through nutrition. One thing I cannot personally stand is a fad diet. Why? Usually fad diets are not sustainable, an individual will probably have success initially by going on a diet then sooner or later they will slip into old habits and re-gain the weight they lost. This sets them up perfectly to be a yo-yo dieter. The diet industry knows this and is making tons of money off of preying on insecurity; as a body-image positive health care practitioner this infuriates me. If you’re a yo-yo dieter, PLEASE come see me, let me help you find ways to sustain healthy eating. Sorry for the rant… and now back to keto…

I realize this post may anger some people who have had great success with the keto diet, please note that is not my intention. This is purely my opinion. I also am aware that we have more to learn about keto, the research is still in its infancy and I am excited to see all the information that comes out on it. My opinion may change with new research coming out but as for now this is my take on the keto diet.

What is the keto diet?

The keto diet is a low carbohydrate, high fat diet, which promotes weight loss through using fat (instead of carbs) for energy. Carbohydrates provide energy for our bodies, when carbs are low in the body we lack the glucose necessary to function, so the body turns on its “back up” mechanism. The mechanism consists of turning fat into something called ketones (via the liver) for energy utilization. Once your body starts burning ketones for energy you enter into a state of ketosis—this is a normal process—it keeps us going if we skip a meal, sleep, or have a strenuous exercise session,  I am thankful this mechanism exists.

The diet generally recommends individuals consume no more than ~20-50 g of total carbohydrates a day, and that 70-80% of their dietary intake comes from fat. This theoretically will drive an individual into ketosis and lead to fat loss.

What are some pitfalls of the keto diet?

Cutting out an entire group of macronutrients
First and foremost, I believe that most individuals should not cut out an entire group of macronutrients. Our macronutrients include carbohydrates, fats, and proteins, and our bodies need them to function optimally. Whenever a diet cuts out one of these important components it is an immediate red flag for me. Now, one may argue that the keto diet doesn’t cut out all carbs it just restricts carbs. Carbs are heavily restricted on the keto diet. The keto diet allows for about 50 g of carbs a day, while someone on the standard 2000 calorie diet (which is a topic for another day) is supposed to eat 225-325 g of carbs a day, you can see there is a drastic difference between the two recommendations.

Carbs in my opinion get a bad rap, as previously mentioned, carbs are our main source of energy. It is a good thing that we have the backup mechanism of burning fat for fuel, however, I believe if this was the best mechanism then we would have evolved in this way. Think of it this way, a hospital uses electricity for power, when we lose power the hospital has an emergency backup generator. This backup generator works great and it keeps people alive, however, once normal power is restored we don’t continue to use the generator, we don’t opt to use the generator because it’s simply not the best choice. I think of ketosis in a similar way, it is a great backup mechanism, however, in most cases; I am not going to continue to utilize it when there is a more favorable mechanism available. Generally, I do opt for a diet of fewer carbs but I don’t heavily restrict them or cut them out completely. Since carbs are a macronutrient I believe them to be essential in our diet, keep in mind that some carbs are better than others, so choose your carbs wisely.

Sustainability
The keto diet is one that is difficult to sustain. It is challenging to remain in a state of ketosis. This diet is heavily restrictive and views food as if it is simply fuel. To me, food is so much more; food is also about celebration, culture, comfort, and connection. Think about all the traditions we have around food. Consider the wedding cake celebrating your daughter or son’s marriage, Grandma’s lefsa over the Holidays, or Dad’s pancakes on Saturday morning—all of these are non-keto friendly but offer something else, something special. When we restrict like this we create a sense of deprivation, we obsess over it which can lead to cheating and binging, then we feel terrible and guilty for days until we can “get back on track.” This disordered thinking is dangerous. What if we just ate healthily and made room for occasional treats such as these? Do you want your life to be counting carbs and checking ketone levels and depriving yourself of the other things food has to offer like joy and connection? In my mind if you can’t do a diet for over 10 years don’t do it, find a better way to be healthy.

Some food for thought…

I also want to note that the restrictive mentality can not only be dangerous, it is the same line of thinking that contributed to the state of obesity today. Years ago, carbs weren’t the bad guys, fats were. Everyone became fat phobic, fat-free, and reduced fat became encouraged and was the norm. Again, when you cut out an entire group of macronutrients there are bound to be some issues. When we cut out huge amounts of fat we substituted with carbs and sugar which led to a very overweight population. Of course fats are ALSO necessary and important so taking them away and adding carbs and sugars had fattening consequences. Now that we have realized this the pendulum has swung the other way and everything is low carb and “fat is your friend”. Could we speculate that in thirty years there will also be unintended consequences of cutting out carbs and eating lots of fats? Then will it swing back the other way? Don’t you think it’d just be easier if we realized that these macronutrients are all important and belong in a healthy and balanced diet?

A lot of people get it wrong
Many people hear they can eat all the fat they want and lots of protein and eat the WRONG kinds of foods. I followed several keto Instagram accounts and was shocked by the piles of food on their plates, none of it was even remotely “healthy,” and most of it was lacking vegetables and fruits. I feel vegetables and fruits are VERY important and necessary. I’ve seen people eat high calorie double bacon cheeseburgers (without the bun) with a side of cottage cheese instead of fries and think that they are eating something healthy because it is keto. Or have five eggs for breakfast smothered in cheese and bacon and washed down with coffee sloshed with butter and think it is healthy. Keto doesn’t always translate into healthy. It is actually easy to go to a fast food place and eat a keto friendly meal but that doesn’t mean that that meal is good for you, it is still heavily processed and high in sodium.  There are RIGHT ways and WRONG ways of doing keto. Keto CAN be done right and I do think it is a diet that can be beneficial for certain individuals. If you really want to do keto your diet should be full of whole foods like fatty fish, coconut, nuts, avocados, organic eggs, limited processed meat, AND yes, vegetables. See the graphic below…

Many also fail on keto by eating too much protein. Protein will pull you out of ketosis. The keto diet is a high fat diet NOT a high protein diet. If you are struggling to stay ketosis check your protein levels. Again, constantly being worried about carbs and protein intake is hard to sustain long term.

Nutrition pitfalls
Often those on the keto diet are not getting enough fiber, this leads to tummy troubles like constipation. Getting enough fiber is key for any diet and when you’re restricting carbs this can be tough to do! Fiber keeps a colon healthy and clean, there have been some questions on whether a keto diet increases the risk of colon cancer.  I personally think that we don’t talk about fiber like we should, it is so essential and can help with satiety, weight control, reducing cancer, reducing heart disease and more. B vitamins and trace minerals are also difficult to get when on a keto diet since many B vitamins are found in whole grains and vegetables. Not getting enough fruits and vegetables which are loaded with nutrients and antioxidants is a big problem for me when it comes to keto. A diet high in red meat can also increase Uric Acid levels which can lead to things like gout. And of course eating a keto diet will increase cholesterol levels, which again, is a topic for another day. I do think we have become perhaps too strict when it comes to cholesterol levels, so this isn’t my main concern with the keto diet, but for someone with a history of heart disease or family history of heart disease, it is something to consider.

What is good about the keto diet?

Keto for weight loss
If someone is very obese, keto may be a good option for them. I would encourage them to work with a dietitian or nutritionist to help them with the process and to ease them back into a normal diet routine once weight loss has been achieved. The keto diet works well for weight loss but again it is difficult to sustain which may cause rebound weight gain. Overall the diet is good for weight loss and improving things like insulin resistance and diabetes.

Keto and neurological disorders
There is exciting research on the effects of a keto diet on neurological disorders such as Multiple Sclerosis, Parkinsons, Epilepsy, and Alzheimer’s. For individuals with these debilitating conditions it may be beneficial to stick with a strict keto diet. Alzheimer’s has recently been referred to as “type III diabetes,” which suggests keto would be beneficial. Keto may be neuroprotective and although the research is still young it will be interesting and exciting to see what comes of it.

Keto and autoimmune and genetic conditions
I have a couple of patients that choose to be on a keto diet because it helps with their advanced and/or rare condition. This is very exciting stuff! For many people it has been life changing. I will always support healing through nutrition and food being used as medicine. Just because keto may have some pitfalls doesn’t mean it isn’t appropriate for certain populations or conditions. Think of it like a prescription, not everyone needs to be on high blood pressure medication, but those with high blood pressure would benefit from being medicated!

What’s the bottom line?
The Keto Diet may be beneficial for some individuals. Many have had great success with the keto diet and I am never going to discourage individuals that are just trying to be healthier. At the end of the day, do what works for you. Do I think it is the best and most sustainable option? No. I personally believe in a balanced approach to nutrition, as this is what is most maintainable. I believe in moderation (even moderation in moderation). If you are confused about nutrition, seek advice from a professional; don’t just jump on the latest bandwagon. And finally, clinically, it will be exciting to see what becomes of the research on keto for certain conditions.

“Eat food. Not too much. Mostly plants.” –Michael Pollan

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Resources

A ketogenic diet favorably affects serum biomarkers for cardiovascular disease in normal-weight men.

M Sharman-W Kraemer-D Love-N Avery-A Gómez-T Scheett-J Volek – https://www.ncbi.nlm.nih.gov/pubmed/12097663/

Diet Review: Ketogenic Diet for Weight Loss

Modification of lipoproteins by very low-carbohydrate diets.

J Volek-M Sharman-C Forsythe – https://www.ncbi.nlm.nih.gov/pubmed/15930434/

The Keto Diet – What this Dietitian ACTUALLY Thinks About a Ketogenic Diet for Weight Loss

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