The Ketogenic Diet
Effective Low-Cost Treatment of Obesity, Type 2 Diabetes Mellitus, and Hypertension
Matthew Zorn, ND
Obesity is a worsening epidemic in the United States. Based on trending data collected between the 1970s and 2004, an estimated 86.3% adults will be overweight or obese by 2030, and 51.1% will be obese.1 These statistics carry a great toll in human suffering. The current dietary recommendations need to be altered to effect a positive, meaningful change in obesity rates.
Causes of Obesity
Obesity is caused by many factors. The most influential causes are errors in diet and lack of physical movement. Many of my patients engage in light to moderate exercise and eat low-fat meals. Very few patients eat high-calorie, high-fat fast food daily. A common factor among most patients is that they consume sugars, carbohydrates, or both several times per day. The main foods that contribute to elevated blood glucose level include cold cereals, bread, rice, pasta, fruit and fruit juice, sweetened drinks, starchy vegetables (carrots, potatoes, and corn), snack foods, food bars, and candy. These foods lead to a spike in blood glucose level. While this provides cells with quick energy, it prevents the body from metabolizing triglycerides. The food pyramid that Americans are encouraged to follow—which recommends 6 to 11 servings of bread, cereal, rice, and pasta—is not conducive to maintaining a healthy body weight or to losing weight. This is because of the emphasis placed on carbohydrate consumption. Other contributing causes to weight gain include stress, lack of sleep, and endocrine disrupters (pesticides, plasticizers, etc),2 as well as the food industry’s trend toward larger portions.
Most patients use a bathroom scale to track their weight loss progress. This is a very inaccurate way of monitoring progress in a weight loss program because the scale only records how hard gravity is pulling the individual to earth. It does not discern between muscle, water, bone, or adipose tissue. It can also be misleading when a person is retaining water and metabolizing fat simultaneously. Many female patients will complain of minimal weight loss before or during their menses. I have found that the most accurate way of tracking progress is to combine the objective data that are gathered by using a scale in conjunction with measuring specific body parts (upper arm, chest, midriff, hips, and thighs) and using a bioimpedance analysis machine and by having patients check for ketosis daily. As long as ketones are present in the urine, the body is actively metabolizing triglycerides.
Comorbidities of Obesity
The list of comorbidities of obesity continues to grow as research advances. It is now recognized that several cancers (breast, uterine, colon, esophageal, kidney, ovarian, and gallbladder), type 2 diabetes mellitus, heart disease, stroke, osteoarthritis, hypertension, sleep apnea, liver and gallbladder disease, hypercholesterolemia, and depression are linked to obesity.3 The risk of these comorbidities diminishes substantially when individuals reduce their body mass index (calculated as weight in kilograms divided by height in meters squared) to the normal healthy range of 18.5 to 25.0.
Type 2 Diabetes Mellitus and the Ketogenic Diet
According to the American Diabetes Association (http://www.diabetes.org), 18.8 million Americans are diagnosed as having type 2 diabetes and another 79 million are prediabetic. The low-calorie ketogenic diet has been shown to be the most effective protocol with regard to weight loss and blood glucose management.4-6 Many patients with diabetes drastically reduce or discontinue their medications after implementing a ketogenic diet.5 Compared with low-fat diets, ketogenic diets have been shown to be more effective at lowering body weight and glycated hemoglobin, low-density lipoprotein cholesterol, and serum triglycerides levels and at elevating high-density lipoprotein cholesterol level.4-6 This diet is so effective that one study5 claimed that the low-calorie ketogenic diet reverses type 2 diabetes. A study7 that reviewed medical records between 1914 and 1922 (before the introduction of insulin) showed that a diet with 70% fat and 8% carbohydrates could eliminate glycosuria among hospitalized patients with diabetes.
Hypertension and Obesity
Hypertension is a common comorbidity of obesity. As a person gains weight, the body has to produce vasculature to keep the added tissue alive. This increase in “tubing” raises the workload on the heart and increases the blood pressure. So naturally, as the patient loses weight, the capillary beds are absorbed, and the blood pressure comes down. This happens in most cases. Patients should be counseled to be aware of symptoms of hypotension within several weeks if they are taking antihypertensives. There is a small group of patients who have hypertension as a result of psychogenic factors. This protocol will not have an effect on the blood pressure of these patients.
Physiologic Ketosis vs Ketoacidosis
Physiologic ketosis occurs as a normal response to a diet that does not elevate the blood glucose level, causing the body to transition to triglycerides metabolism to derive caloric energy. Dietary sugars and carbohydrates are the main source of calories that elevate blood glucose level, preventing lipolysis and ketosis. Most patients require 24 to 72 hours before entering into ketosis after the cessation of consuming sugars and carbohydrates. Physiologic ketosis is not a “starvation” state. In ketosis, fats are primarily being metabolized, and muscle is spared. During starvation, the body metabolizes large quantities of muscle, and individuals report being very hungry and fatigued. They can inadvertently push their bodies into a state of starvation by combining a reduced caloric intake with a diet that has moderate sugar and carbohydrate portions. What options does the body have when a person consumes only a low-fat yogurt with fruit for breakfast, a granola bar for a snack, and a nonfat latte or piece of fruit throughout the day? In this common scenario, the body has little chance of pulling caloric energy out of adipose tissue owing to the frequent spikes in blood glucose level.
Ketoacidosis is a pathological metabolic state marked by severe and uncontrolled ketosis. In ketoacidosis, the body fails to adequately regulate ketone production, causing such a severe accumulation of ketoacids that the pH of the blood is substantially decreased. The excessive production of ketones is due to (1) a lack of insulin production from the beta cells in the pancreas (type 1 diabetes) or (2) insulin resistance. Insulin is absolutely vital for the transfer of glucose from the blood into cells. In both situations, cells are being prevented from deriving energy from glucose, so they send out chemical signals that prompt excessive ketone production via lipolysis.
Ketones are small organic molecules that the human body uses for energy when there is insufficient glucose available. The ketogenic diet should start with 2 days of loading. Patients who do not load tend to lose weight more slowly and complain of hunger more frequently. Loading consists of overeating high-fat foods in an effort to temporarily raise the serum triglycerides level. This seems to prepare the body for a low-calorie ketogenic phase that can last several weeks to a few months. The diet consists of 3.5 to 5.0 oz of protein per meal, depending on the patient’s basal metabolic rate. Men with a small to medium frame and most women should start with 3.5 oz because of similar basal metabolic rates. This is in conjunction with a handful of vegetables. Potatoes, corn, carrots, and other starchy vegetables are not allowed. Foods can be seasoned and spiced with herbs and other condiments that do not contain sugars. All food consumed should be salted to replenish the sodium that is lost due to ketosis. Lunch can be anytime between 11 am and 2 pm. Dinner should be no later than 8 pm. Several ounces of protein or an egg can be eaten between meals if unmanageable hunger is present. Breakfast is usually skipped unless the patient requires protein to get the day started. Remember, this protocol is for overweight and obese patients who have tens of thousands of calories stored in adipose tissue.
While it is widely accepted that a higher caloric intake and sedentary lifestyle have a role in contributing to the obesity epidemic, less emphasis is placed on the type of calories a person consumes. Sugars and carbohydrates have a deleterious effect on weight gain, weight management, and blood glucose regulation. The human body derives energy to function by metabolizing sugars, carbohydrates, triglycerides, and proteins. Triglycerides and sugars/carbohydrates cannot be metabolized simultaneously. This is evident when monitoring ketones using a urine dipstick. Ketones are the by-product of fat metabolism. When patients are in ketosis and introduce sugars or simple carbohydrates into their diet, they will invariably knock themselves out of ketosis. The body is always looking to get the greatest return on energy spent. So, why would the body go through all the hassle of liberating calories from triglycerides stored in adipose tissue when there is a quick, easy energy source in the form of elevated blood glucose level? This is why many individuals continue to gain or cannot lose weight on low-fat diets that still contain substantial amounts of sugars and carbohydrates.
The length of time that patients should be kept on a ketogenic diet depends on how well they tolerate the protocol, how much weight they need to lose, and their level of commitment. Most patients can tolerate 6 to 12 weeks without any issues. Some investigations have found long-term ketogenic diets, up to 6 months, to be safe.8
Managing Patients Throughout the Program
Managing patients on a ketogenic diet takes practice. Many patients need to be seen to become proficient in understanding and addressing concerns, questions, and complaints that may come up while they are following a ketogenic diet. The most common issues that arise are constipation, weight plateaus, hunger, and questions about exercise and different foods. Constipation occurs because of the lack of fiber and the diminished volume of food on the protocol. This is usually remedied with ground flaxseeds (2 tablespoons 1-2 times per day). Another effective remedy for constipation is magnesium supplementation. I usually start with 600 mg/d and titrate up until the patient reports relief. Patients should not do strenuous exercise on a low-calorie ketogenic diet. Walking, stretching, and yoga are sufficient. Weight lifting is contraindicated. Weight plateaus can be frustrating for patients. Be sure they are checking their ketones daily, and remind them that if they are registering ketones, their body is metabolizing fat. The symptom of hunger can usually be attributed to excessive exercise, consumption of foods that stop ketosis, insufficient protein intake, or extreme stress. Prolonged ketosis can leach the body of sodium, potassium, and magnesium. For all patients, it is necessary that they salt their meals. Patients with a history of muscle cramps are required to supplement their diet with magnesium as well.
Patients on antihypertensives and diabetes medication need to be monitored for orthostatic hypotension and hypoglycemia. Medications are to be tapered by the prescribing physician as needed.
Matthew Zorn, ND has been practicing naturopathic medicine since graduating from National College of Naturopathic Medicine (Portland, Oregon) in 2002. His practice in Portland consists mainly of homeopathy and holistic weight loss. He helps teach yogic philosophy and meditation at the Vancouver Yoga Center, in Vancouver, Washington. He also studies and teaches Brazilian jiu jitsu. Dr Zorn can be reached at firstname.lastname@example.org or at 503-449-4179.
- Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Will all Americans become overweight or obese? estimating the progression and cost of the US obesity epidemic. Obesity (Silver Spring). 2008;16:2323-2330.
- Newbold RR, Padilla-Banks E, Jefferson WN, Heindel JJ. Effects of endocrine disruptors on obesity. Int J Androl. 2008;31:201-208.
- Pi-Sunyer FX. Comorbidities of overweight and obesity: current evidence and research issues. Med Sci Sports Exerc. 1999;31(11)(suppl):S602-S608.
- Yancy WS Jr, Foy M, Chalecki AM, Vernon MC, Westman EC. A low-carbohydrate, ketogenic diet to treat type 2 diabetes. Nutr Metab (Lond). 2005;2:e34. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1325029/?tool=pubmed. Accessed November 23, 2011.
- Westman EC, Yancy WS Jr, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low–glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab (Lond). 2008;5:e36. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633336/?tool=pubmed. Accessed November 23, 2011.
- Yancy WS Jr, Olsen MK, Guyton JR, Bakst RP, Westman EC. A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern Med. 2004;140(10):769-777.
- Westman EC, Yancy WS Jr, Humphreys M. Dietary treatment of diabetes mellitus in the pre-insulin era (1914-1922). Perspect Biol Med. 2006;49(1):77-83.
- Dashti HM, Mathew TC, Hussein T, et al. Long-term effects of a ketogenic diet in obese patients. Exp Clin Cardiol. 2004;9(3):200-205.