In October 2023, the American Academy of Pediatrics (AAP) published a report examining low-carbohydrate diets like keto in children and adolescents. You probably won’t be surprised that the authors are concerned. Despite the increasing popularity of carbohydrate restriction, evidence to support the benefits of low-carb diets in young people under 18 with obesity or diabetes is very limited. And though diabetes authorities have acknowledged that carb restriction has “the most evidence” for improving blood sugar levels, the American Diabetes Association has only endorsed low-carb eating as one of multiple possible eating patterns.
And yet, there are many people in the diabetes community who believe in the effectiveness of low, even very-low, carbohydrate diets for their children. There’s at least one study that supports their advocacy
I’m not a pediatrician and never treat children in my hospital practice, not even 17-year-olds. Nor have I reviewed the pertinent pediatric scientific literature. So I’ve never been comfortable writing about keto diets for children. The linked DD article was reviewed by Anna Goldman, M.D.
Frontiers In Nutrition in July, 2022, published “Fad Diets: Facts and Fiction.” Thank you, FIN, for making it available at no cost. The authors are based in Pakistan and Romania. They attempted to summarize the literature on popular fad diets. I am shocked that they included the Mediterranean diet. Read the article and 134 references then form your own opinion. Some snippets:
Regarding the Atkins Diet: “AD provides several benefits including weight reduction and cardio-metabolic health improvement, but limited evidence exists as compliance is the major barrier to this dietary regimen. Strict supervision by health professionals is advised as adverse metabolic sequelae can result from this type of diet.”
The Paleolithic Diet: “More randomized trials need to be done to highlight the consequences of such diets that eliminate one or more food groups. PD is powerful at advancing weight reduction for the time being but its efficacy in cardiovascular events is not well established as limited long-term data is available.”
Mediterranean Diet: “No evidence of adverse effects associated with MD is available in the literature. Rather, MD has preventive and therapeutic potential for many chronic diseases. It is highly suitable for the general public for the prevention of micronutrient deficiencies and specifically for those patients who are more health-conscious than just weight loss oriented.”
Vegetarian Diet: “No evidence of adverse effects associated with MD is available in the literature. Rather, MD has preventive and therapeutic potential for many chronic diseases. It is highly suitable for the general public for the prevention of micronutrient deficiencies and specifically for those patients who are more health-conscious than just weight loss oriented.”
Intermittent Fasting: “Despite the effectiveness of IF in weight loss as indicated by several studies, the current evidence is non-conclusive. The prime focus of available literature is weight loss but little is known about its sustainability and long-term health effects. More long-term trials should be conducted to draw a clear conclusion.”
Detox Diets: “Energy-restricted DDs are capable of short-term weight loss. But still, there is a high likelihood of health risks from detox products because of their nutritional inadequacy. As no convincing evidence exists in this domain so such diets and products need to be discouraged by health professionals and must be subjected to regulatory review and monitoring.”
The American Diabetes Association has identified low-carbohydrate (LC) and very low-carbohydrate (VLC) eating patterns as options that can improve outcomes in adults with type 2 diabetes. This 28-page guide was designed to assist registered dietitians, certified diabetes care & education specialists, and other health care practitioners in assessing the appropriateness of a LC or VLC intervention for their patients. Additionally, it provides strategies and sample meal plans for implementing a LC or VLC eating pattern as an evidence-based intervention in adult with type 2 diabetes.
In my world, “very low-carbohydrate” means ketogenic.
Right off the bat, I don’t like that they studied both diabetics and prediabetics. There were only 40 original study participants, with complete data on only 33. Why lump the two together?
Participants followed each diet for 12 weeks then lab data and body weight were assessed.
The researchers conclusions:
HbA1c [a measure of blood sugar control] was not different between diet phases after 12-weeks, but improved from baseline on both diets, likely due to several shared dietary aspects. WFKD [ketogenic diet] was beneficial for greater decrease in triglycerides, but also had potential untoward risks from elevated LDL-C, and lower nutrient intakes from avoiding legumes, fruits, and whole intact grains, as well as being less sustainable.
Triglycerides dropped more on the keto diet, no surprise. Body weight dropped the same for both diets, 7-8%. HDL-cholesterol (the “good cholesterol”) rose 11% on keto and 7% on Mediterranean diet. HgbA1c dropped the same on both diets, about 8% from baseline. Both diets lead to eating ~300 calories less per day than baseline consumption.
The authors reported that LDL “dangerously” rose 10% on the keto diet. But was it really a dangerous change? Triglycerides went down on the keto diet, as we would expect. And as we saw in 2018 with the Virta Health trial, on average, LDL went up 10%. However, the calculated cardiac risk score went down 12%.
In terms of answering the headline question, Keto Versus Mediterranean Diet: Which Is Best for T2 Diabetics and Prediabetics?, the answer really depends on long-term data concerning longevity and various diseases. This study doesn’t answer the question.
Whether you are traveling and can’t cook or you are celebrating something special with people you love, Olive Garden has some low-carb options that are simply delicious!
They might be known for their endless breadsticks and overflowing plates of pasta, but there are some keto-friendly choices on the menu, too. You just have to know where to look.
Olive Garden is also known for its large portions, so you will have to think ahead before eating everything on your plate.
When you don’t have time to cook or just want to dine out, Olive Garden can be an appealing option for people on a ketogenic diet. Thankfully, there are ways to eat a keto meal at Olive Garden – you just have to be a little creative with a custom order!
Thank you, Lisa.
Steve Parker, M.D.
PS: Conquer Diabetes and Prediabetes includes a ketogenic option.
The study at hand was very small, only 20 participants. So results may not be reproducible. The Canadian researchers’ main conclusion: “This is the longest duration MCT Alzheimer Disease study to date. Eighty percent had stabilization or improvement in cognition, and better response with 9‐month continual MCT oil.”
MCT stands for medium chain triglycerides, which apparently are derived from coconut and palm oil. The MCTs provide a source of energy for the brain – ketones – as a partial substitute for the brain’s usual energy source, glucose.
Study participants as expected were elderly and had mild to moderate Alzheimer Disease. Folks with diabetes were excluded from participation.
The article introduction has some interesting facts:
The brain is an obligate glucose metabolizer using 120 to 130 g/day of glucose. It uses 16% of the body’s total O2 consumption, despite representing only 2.0% to 2.3% of adult body weight. In conditions of low carbohydrate intake or fasting, the body uses ketones (acetoacetate and beta hydroxybutyrate [BHB]) as an alternative energy source to glucose. Ketones are normally generated in fasting states from beta‐oxidation of adipose stores to maintain cerebral function. In long‐term fasting, ketones can supply > 60% of the brain’s energy requirements, and are preferentially taken up by the brain over glucose. This occurs in cognitively normal younger and older adults, as well as in those with mild cognitive impairment (MCI) and AD.
Ketones can also be induced with a very low carbohydrate high fat (VLCHF) diet. Medium chain triglyceride (MCT) oil has the potential to produce a nutritional source of ketones for an alternative brain fuel to glucose, or by the consumption of MCT oil or esterases in freeze‐dried form. This is independent of the fasting state or carbohydrate intake. Long‐term compliance with fasting or VLCHF and LCHF diet regimes is challenging and requires strict medical supervision. Hence, the potential advantage of nutritional ketone sources (MCT) over these restrictive diets. Our recent study showed a clear dose‐dependent effect on ketone (BHB) generation with varying doses of MCT supplementation, and was found to be equivalent in young, elderly, and AD subjects.
In Alzheimer Disease (AD), the brain is unable to use glucose normally, causing hypofunction of 20% to 40% in key areas of the brain responsible for the symptoms in AD.
The MCT oil used was Bulletproof Brain Octane ® (NPN 80057199). Are other MCT oils just as good? Hell if I know. The goal dose was three tablespoons (15 ml) daily. My sense is that it was recommended as one tablespoon (15 ml) three times daily. The average consumption ended up as two tablespoons daily. Caregivers were in charge of dosing and they tended to forget or omit the lunchtime dose. Some study participants had limited dosing due to MCT side effects: abdominal pain, diarrhea, or vomiting.
Conclusion:
This study shows that participants taking MCT supplementation for 11 months continuously did better cognitively than their peers who had their 11 months of MCT interrupted by 4 months of placebo (olive) oil. Given that most patients should experience a drop in their cognitive scores over the 15 months, the fact that those on longer continuous MCT did not, could be a sample size error for the outcomes other than Montreal Cognitive Assessment, but it could also be that the difference in scores (showing stability) is valid.
In other words, MCT oil didn’t improve cognition, but stabilized it. I.e., it prevented the usual expected decline over time.
Judicious alcohol consumption is a reasonable component of many successful ketogenic diets. But the practice can also be a dangerous minefield. Anne Mullins over at DietDoctor has a great article that will steer you away from the mines. An excerpt:
Nyström notes that alcohol is actually the fourth macronutrient after protein, fats and carbohydrates, and that in many nutrition studies its intake is often overlooked. In Mediterranean countries like Greece and Italy, alcohol makes up about 10 % of caloric intake and may partially contribute to the touted benefits of the Mediterranean diet, Nyström says.
Drinking alcohol, however, may slow weight loss for some. Dr. Sarah Hallberg advises her patients who are trying to lose weight and/or reverse diabetes to have a maximum 1 glass of wine for women and 2 for men, and not every day. “If they experience any weight stall, I recommend they stop the alcohol completely,” says Hallberg.
Both Dr. Jason Fung and Dr. Ted Naiman discourage any alcohol use among patients in their care who are still trying to lose weight, reverse diabetes or heal a fatty liver (see point 5). “I find alcohol is not conducive to steady weight loss,” says Fung.
Read the whole thing to learn about the dopamine reward system, alcohol abuse and addiction, liver diseases, and worse hangovers. If you regularly drink to the point of hangovers, that’s too much alcohol!
Steve Parker, M.D.
PS: Conquer Diabetes and Prediabetes includes a doctor-designed ketogenic diet as one option for weight loss and diabetes management.
Here’s the abstract of an article in Advances in Nutrition. This is the first I’ve heard of “gray literature.”
Alzheimer disease (AD) is a global health concern with the majority of pharmacotherapy choices consisting of symptomatic treatment. Recently, ketogenic therapies have been tested in randomized controlled trials (RCTs), focusing on delaying disease progression and ameliorating cognitive function. The present systematic review aimed to aggregate the results of trials examining the effects of ketogenic therapy on patients with AD/mild cognitive impairment (MCI). A systematic search was conducted on PubMed, CENTRAL, clinicaltrials.gov, and gray literature for RCTs [randomized controlled trials] performed on adults, published in English until 1 April, 2019, assessing the effects of ketogenic therapy on MCI and/or AD compared against placebo, usual diet, or meals lacking ketogenic agents. Two researchers independently extracted data and assessed risk of bias with the Cochrane tool. A total of 10 RCTs were identified, fulfilling the inclusion criteria. Interventions were heterogeneous, acute or long term (45-180 d), including adherence to a ketogenic diet, intake of ready-to-consume drinks, medium-chain triglyceride (MCT) powder for drinks preparation, yoghurt enriched with MCTs , MCT capsules, and ketogenic formulas/meals. The use of ketoneurotherapeutics proved effective in improving general cognition using the Alzheimer’s Disease Assessment Scale-Cognitive, in interventions of either duration. In addition, long-term ketogenic therapy improved episodic and secondary memory. Psychological health, executive ability, and attention were not improved. Increases in blood ketone concentrations were unanimous and correlated to the neurocognitive battery based on various tests. Cerebral ketone uptake and utilization were improved, as indicated by the global brain cerebral metabolic rate for ketones and [11C] acetoacetate. Ketone concentrations and cognitive performance differed between APOE ε4(+) and APOE ε4(-) participants, indicating a delayed response among the former and an improved response among the latter. Although research on the subject is still in the early stages and highly heterogeneous in terms of study design, interventions, and outcome measures, ketogenic therapy appears promising in improving both acute and long-term cognition among patients with AD/MCI. This systematic review was registered at http://www.crd.york.ac.uk/prospero as CRD42019128311.
For >50 [years], dietary guidelines in the United States have focused on reducing intakes of saturated and total fat. However, rates of obesity and diabetes rose markedly throughout this period, with potentially catastrophic implications for public health and the economy. Recently, ketogenic diets have received substantial attention from the general public and nutrition research community. These very-low-carbohydrate diets, with fat comprising >70% of calories, have been dismissed as fads. However, they have a long history in clinical medicine and human evolution. Ketogenic diets appear to be more effective than low-fat diets for treatment of obesity and diabetes. In addition to the reductions in blood glucose and insulin achievable through carbohydrate restriction, chronic ketosis might confer unique metabolic benefits of relevance to cancer, neurodegenerative conditions, and other diseases associated with insulin resistance. Based on available evidence, a well-formulated ketogenic diet does not appear to have major safety concerns for the general public and can be considered a first-line approach for obesity and diabetes. High-quality clinical trials of ketogenic diets will be needed to assess important questions about their long-term effects and full potential in clinical medicine.
The headline says it all. Read below if you want details. What stands out to me is that they started these guinea pigs on a diet of under 500 calories/day for four weeks. I bet their drop-out rate was high because that’s not many calories. I wouldn’t ask you to go that low. But it probably helped these overweight/obese folks lose an average of 23 pounds in 10 weeks.
My book gives you a ketogenic diet without calorie restriction, followed by a Mediterranean diet. I don’t guarantee it’ll improve your psoriasis. But it might!
Objectives
Very low-calorie ketogenic diet (VLCKD) has been associated with a significant reduction in visceral adipose tissue and ketone bodies likely possessing anti-inflammatory properties. We evaluated the efficacy of an aggressive WL [weight loss?] program with a ketogenic induction phase as first-line treatment for chronic plaque psoriasis.
Research methods & procedures
Adult overweight/obese drug-naïve (never treated excluding use of topical emollients) patients (N=37; 30% males; age, 43.1±13.8 years) with stable chronic plaque psoriasis underwent a 10-week two-phase WL program consisting in a 4-week protein-sparing, VLCKD (<500 kcal/day; 1.2 grams of protein/kg of ideal body weight/day) and a 6-week balanced, hypocaloric (25-30 kcal/kg of ideal body weight/day), Mediterranean-like diet. The primary endpoint was the reduction in the Psoriasis Area and Severity Index (PASI) at week 10. Major secondary endpoints included: PASI50 and PASI75 response, reduction in body surface area (BSA) involved, improvement in itch severity (visual-analogue scale) and Dermatology Life Quality Index (DLQI) at week 10.
Results
With a mean body weight reduction of 12.0% (-10.6 kg), dietary intervention resulted in a significant reduction in PASI (baseline score, 13.8±6.9 [range, 7-32]): mean change, -10.6 [95%CI, -12.8 to -8.4] (P<0.001). A PASI50 and PASI75 response was recorded in 36 (97.3%) and 24 (64.9%) patients, respectively. Treatment resulted also in a significant reduction (P<0.001) in BSA involved (-17.4%) and an improvement in itch severity (-33.2 points) and DLQI (-13.4 points).
Conclusions
In drug-naïve adult overweight [what about obese?] patients with stable chronic plaque psoriasis an aggressive dietary WL program consisting in a very low-calorie ketogenic regimen followed by a balanced, hypocaloric Mediterranean-like diet appeared to be an efficacious first-line strategy for improving disease severity.
Diabetic Mediterranean Diet 