Is it possible to do keto in a healthy way? (2024)

Over the past couple of decades I have heard talk about all kinds of diets that people having been going on, such as a number of people diplomatically asking me while I was overweight: “hey Daniel, have you heard of the Palaeolithic diet? Apparently it’s really good.” Yet many of these diets seem to have been based on the same premise - sending the body into ketosis in order for it to burn fat instead of glucose as an energy source. I then avoided these types of diets for many years from being sceptical about consuming high levels of the kind of fat that can congeal on a plate, along with having the mistaken belief that all ketogenic diets involve consuming high levels of protein. During the research for this article I found that while a high level of fat is indeed required on a ketogenic diet, that a lot of information is still up in the air about various other pros and cons to this type of diet which are well worth considering.

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Takeaway:in this blog I will explore what the actual mechanisms for a ketogenic diet involve beyond the obvious restriction of carbohydrates, and find that this type of diet is still a new frontier to science. The topic is also explored in that while the body needs to switch to an alternative energy source involving ketones with such a diet, that just how long this energy switch takes might be hampered by the ketogenic dieter’s current weight condition and resting metabolic rate. The fact that carbohydrates are often confused with calories is then discussed, and where it is found that carbs, proteins, and fats actually contain vital nutrition rather than just being factors in weight gain. I also find to my surprise that proteins can convert into glucose, thereby indicating that ketogenic diets are not high protein diets (unless the dieter is a bodybuilder).

The role of the liver as being a key player in the success of a ketogenic diet is then discussed since this is the internal organ that produces ketones. Therefore, the liver being in reasonable working order is found to be a prerequisite for the production of ketones, especially since a fatty liver that is still in a world of sugar will have a much more difficult time in switching away from producing glucose as the body’s main energy source. The very interesting topic of whether the brain can run on ketones for the long-term is then explored given that neurodegenerative diseases, such as Alzheimer’s disease, have shown positive responses to ketones as an alternative energy source in terms of bypassing the glucose burnout of brain cells.

It will then be considered that not all things about a ketogenic diet are beneficial given research evidence demonstrating that such a diet can double the risk of cardiac disease and strokes, although it is also put forward that currently undiscovered individual genetic factors might also contribute to such health issues occurring. Finally, I will discuss how evidence has been found that being on a ketogenic diet not only does not necessarily mean that there will be a loss of muscle mass, but where bodybuilders taking a ketone supplement were found to have doubled their level of muscle protein synthesis.

After all of these topics have been considered, the blog will conclude with the consideration that there are still mixed reports about ketogenic diets from a lack of research evidence available, and that the potentially beneficial possibilities of the ketogenic diet might indicate that this area of research is not only still an open book, but that it is still an unexplored frontier for both dieters and the medical field.

What is a ketogenic diet?

The term “keto” can become somewhat of a buzzword when dieting is being discussed. The right setting also needs to be established since in the context of diabetes, ketones are something negative that happens once the cells become desensitized to any and all glucose (see the blog “Diabetes and chronic kidney disease (CKD)” for more info). At the same time, what is negative in one context is positive in another, such as a person volunteering to go on a ketogenic diet in order to lose weight, and when their kidneys are otherwise in a relatively healthy state. If buzzwords are to be avoided and the facts dealt with in an objective fashion, then what exactly is a ketogenic diet? The Harvard T.H. Chan School of Public Health describes this diet as follows:

“The premise of the ketogenic diet for weight loss is that you deprive the body of glucose - the main source of energy for all cells in the body, which is obtained by eating carbohydrate foods - an alternative fuel called ketones is produced from stored fat (thus, the term “keto” - genic). The brain demands the most glucose in a steady supply, about 120 grams daily, because it cannot store glucose. During fasting, or when very little carbohydrate is eaten, the body first pulls stored glucose from the liver and temporarily breaks down muscle to release glucose. If this continues for 3-4 days and stored glucose is fully depleted, blood levels of a hormone called insulin decrease, and the body begins to use fat as its primary fuel. The liver produces ketone bodies from fat, which can be used in the absence of glucose.”

This passage actually explains something for myself in that it is more difficult to send the body into ketosis if there is more excess weight to deal with (see the blog “Introduction to ‘You Must Eat’”), and where it is the case that the liver has to run out of stored glucose first before it can start really producing ketones. For instance, the same source also mentions:

“How soon ketosis happens and the number of ketone bodies that accumulate in the blood is variable from person to person and depends on factors such as body fat percentage and resting metabolic rate.”

It is interesting that the condition of the metabolism is also mentioned here, and where it is presumed that if the metabolism isn’t firing well in all of the body cells, then ketosis is not going to happen in a hurry (for further information on this topic, please refer to the blog “Prepping for weight loss 02 - Know your metabolism”). Another vital point to consider here, since metabolism refers to the burning of energy, is that the liver produces ketones from fat, and that this is how fat ends up being used as an energy source. Healthline then mentions that fats are actually consumed as the central premise of a ketogenic diet:

“The ketogenic diet is a very low carb, high fat diet that shares many similarities with the Atkins and low carb diets.

It involves drastically reducing carbohydrate intake and replacing it with fat. This reduction in carbs puts your body into a metabolic state called ketosis.

When this happens, your body becomes incredibly efficient at burning fat for energy. It also turns fat into ketones in the liver, which can supply energy for the brain.

Ketogenic diets can cause significant reductions in blood sugar and insulin levels. This, along with the increased ketones, has some health benefits.”

Health Direct emphasises the increased consumption of fats that takes place on this diet, and seems to take an opposite stance regarding how the brain uses energy:

“When you are on a ketogenic diet, you eat a very small amount of carbohydrates, some protein and a high amount of fat every day. Your body breaks down fat into ‘ketone bodies’ (or ‘ketones’) as energy through a process called ketosis. Some parts of your body, such as the brain and red blood cells, need glucose to work and can’t use ketones for energy. The body will break down proteins from food or your muscle to make glucose.”

The premise that an intake of fat is required for a ketogenic diet is logically consistent given that this is the source for ketones, but where it is not mentioned who would be more advised to consume more fats, ie. would an athlete or someone working out at the gym have a higher intake of fats compared to the overweight person who just wants all of the fat that they already have to be burned up for energy? The answer to this might depend on the context, where of course the overweight person is not so much concerned with toning their physique as they are in just wanting to lose weight. In this regard, it is then interesting to consider whether the overweight person can simply cut their carb and sugar intake without necessarily going out and buying a few kilos of pork chops and bacon for their daily sustenance. I would suggest from my own experience that this is the case. For instance, as of today’s date (May 2024), I have lost 9 kilos since New Year just by diet alone from mostly cutting down an carbs and sugar, but without going overboard in terms of consuming various slabs of meat. This diet has involved the same principle of ketosis, but where I am not consuming any fats besides some walnuts and cheese in my daily salad. This is to say, as of present I have cut-out as many carbs and sugars as possible from my diet, along with only consuming moderate levels of polyunsaturated fats, and where this has so far been completely successful. However, the question would arise about what I would do if I started to become underweight from this diet, and where the answer would be that I would most likely reintroduce mild levels of sugar and maybe some more fats into my diet which don’t have to be pizzas and hamburgers, but which can include eggs, nuts, fish, meat, and healthy oils (source: Healthline). Furthermore, if I were somewhat underweight while introducing more fats, and as long as I am not a smoker, then there would generally be much less risk of compounding any high cholesterol that might be in my system compared to if I was still obese. Having said this, the results of undertaking a ketogenic diet are well-established when this statement from Healthline is considered:

“Another study of 34 older adults found that those who followed a ketogenic diet for 8 weeks lost nearly five times as much body fat as those who followed a low fat diet.”

This is an astounding statistic. The following passage from Everyday Health then confirms why it is important to cover the topic of fat intake in the context of a ketogenic diet since the amount of this intake covers 80 to 90 percent of the diet!:

“But in the classic ketogenic diet, which was developed a century ago to manage seizure disorders, carbohydrates and protein combined to make up less than 20 percent of your daily calories, while 80 to 90 percent of calories come from fat. That’s according to the Epilepsy Foundation.

Today’s version of the ketones diet allows you to eat protein more liberally - about 20 percent of your total calories - but keep carbohydrates restricted to 10 percent or less.”

In then returning to the Harvard article, which outlines these ketogenic dietary requirements in more detail, I was surprised to find that high levels of protein can actually prevent ketosis from occurring. Up until this point I had considered high protein levels as being a primary feature of a ketogenic diet:

“There is not one ‘standard’ ketogenic diet with a specific ratio of macronutrients (carbohydrates, protein, fat). The ketogenic diet typically reduces total carbohydrate intake to less than 50 grams a day - less than the amount found in a medium plain bagel - and can be as low as 20 grams a day. Generally, popular ketogenic resources suggest an average of 70-80% fat from total daily calories, 5-10% carbohydrate, and 10-20% protein. For a 2000-calorie diet, this translates to about 165 grams fat, 40 grams carbohydrate, and 75 grams protein. The protein amount on the ketogenic diet is kept moderate in comparison with other low-carb high-protein diets, because eating too much protein can prevent ketosis. The amino acids in protein can be converted to glucose, so a ketogenic diet specifies enough protein to preserve lean body mass including muscle, but that will still cause ketosis.”

The last point mentioned here will be important for a subsequent discussion about how bodybuilders using a ketone supplement not only did not lose any muscle, but instead doubled their level of muscle protein synthesis. In the meantime, while I have provided a number of references so far, this has been important in getting a foothold about what a ketogenic diet is about rather than, as mentioned, referring to it as a buzzword. The following points about this particular type of diet have now been discerned:

a ketogenic diet deprives the body of glucose
glucose is obtained by eating carbohydrates
when there are no more dietary carbs, the body pulls glucose from the liver and muscles until it is depleted
since the role of insulin is to transport glucose into the cells, insulin decreases when glucose is depleted
the liver produces ketones from stored fat as an alternative source of energy
proteins might prevent ketosis since they convert into glucose
whether a person can go into ketosis quickly depends on their amount of body fat and resting metabolic rate
about 80% of a ketogenic diet involves an intake of fat
from one’s own experience, ketosis and weight loss can occur without consuming animal fats

Before continuing with this investigation of how to lose weight through activating ketosis, some basic definitions will be considered.

Carbohydrates, macronutrients, and micronutrients

The term “carbohydrates” is mentioned constantly in the context of a ketogenic diet, but without any recourse to what a carbohydrate actually is. The website MedlinePlus provides the following definition:

The liver is the key to a successful ketogenic diet

When most people think of conditions possibly affecting the liver, they usually only think of two things - hepatitis and cirrhosis. However, having hepatitis of the liver is still fairly common in the West (with the exception of hep C). Yet what is often overlooked for a dieter is that the liver is the primary organ determining whether or not their diet will be successful. For instance, if someone diets for only a couple of weeks but doesn’t see any result of weight loss, and where their body is acting as though everything is still business as usual even with the reduced food intake, then this could mean that the body is cruising on a mass of stored glucose in the liver. The website Diabetes Education Online, which is a teaching centre at the University of California, mentions this point:

“When you’re not eating - especially overnight or between meals, the body has to make its own sugar. The liver supplies sugar or glucose by turning glycogen into glucose in a process called glycogenolysis. The liver also can manufacture necessary sugar or glucose by harvesting amino acids, waste products and fat byproducts. This process is called glucogenesis.”

It can then be seen that if the liver is still full of glucose, then the hapless dieter might find their own livers working against them to keep them fat while they are asleep! Even the major burger chains aren’t this sneaky. While Diabetes Education Online maintains that the liver is the body’s “glucose reservoir” for storing glucose, the British Liver Trust more explicitly equates glucose with fat:

“When we eat a meal containing sugar, our bodies break it down into glucose. Our body uses some of the glucose immediately, for energy, and saves some of it for later. Any excess glucose in the blood is turned into fat cells.

The liver is one of the places in our bodies that stores this excess fat. Over time, liver cells are gradually replaced by fat cells, leading to non-alcohol related fatty liver disease.”

This passage paints quite a bleak picture given the proposition that fat cells can actually take over the liver, and where this can cause as much damage to the liver as someone with a major drinking problem. The British Liver Trust then states how too much sugar can reinforce this damage:

“When we eat sugar, our bodies also release inflammatory chemicals. If we eat sugar on a regular basis, the chemicals build up in our bodies affecting our liver and some other internal organs, which can eventually lead to liver damage. When the liver is damaged, fatty or inflamed, it can’t work as efficiently as a healthy liver. It can’t process toxins and eliminate toxins from our body. It also burns less excess fat and cholesterol, leading to even more fatty deposits in the liver and weight gain.”

Of course, the premise of a ketogenic diet is that all of these fatty liver cells will eventually be consumed as an alternative energy source. Yet this passage would make it obvious that if a person who is going onto a ketogenic diet has a liver which is in really bad shape, then it is likely that going into ketosis for that person is going to take a lot longer than it would with someone who has a relatively healthy liver. If someone is then really overweight, it might take at least a month of low-fat and low-sugar dieting before their liver is in reasonable shape for weight loss to even be considered, and also before a serious keto-diet can become a viable option (depending of what a medical professional might advise). The British Liver Trust then states that the liver can begin to regenerate itself if more fruits and vegetables are consumed, but where of course this is not the same thing as a high-fat ketogenic diet. As alluded to previously, medical advice would most likely be needed for someone who likely has a fatty liver if they wish to undertake a keto-diet. In then investigating whether anyone has done research into the specific effects of a ketogenic diet on the liver, an excerpt from the following paper was found (source: NIH - only the abstract is now available although the PDF can be located as a scholarly article):

“The ketogenic diet has both benefits and risks. Advantages of the diet include weight loss, reduction in cravings and appetite (likely due to the satiating effects of fat and protein as well as the stabilising effect on blood sugar levels), and a more stable flow of energy to organs and tissues, due to the reliance of fat catabolism rather than dietary intake for energy. The weight loss occurs partly due to the diuretic effect of glycogen utilisation and the likely calorie reduction resulting from the restricted dietary variety, but primarily because the reduction in blood glucose and insulin leads to less fat storage, as insulin is known to promote the conversion of excess glucose to fat. Research also suggests that the ketogenic diet improves insulin sensitivity and glycemic control, although the mechanisms are unclear.

One potential risk of the ketogenic diet is an increase in LDL-C, TC and liver enzymes. Notably, in rodents, development of nonalcoholic fatty liver disease (NAFLD) and insulin resistance have been described. Despite this risk, some studies show that the higher-risk small dense LDL particles were decreased in individuals on a ketogenic diet, while HDL cholesterol and triglycerides tend to improve. It should be noted, however, that the reduction in small dense LDL particles is observed only in individuals with certain variants of the apolipoprotein gene which is known to play a role in lipid metabolism. Depending on an individual’s responsibility to the diet, benefits of improved glycemic control may outweigh potential risks of an elevated LDL. One way to mitigate the negative effects of the diet on LDL cholesterol is to replace saturated fats from animal sources with polyunsaturated fats found in avocados, nuts, seeds, coconut and olive oil.”

What is pretty much being stated here is that there might indeed be a risk of a ketogenic diet leading to an increase in cholesterol levels, but where this is a trade-off with achieving good blood-glucose levels. There are even animal studies supporting the case that the liver might not respond well to a high-fat diet. This same research paper, in its conclusion, confirms what I also found out to be the case on an Atkins diet of only having success for the first two or so times of using that diet:

“The ketogenic diet is a high-fat, moderate-protein, low-carbohydrate diet that can induce weight loss and improvement in glycemic control, but poses a risk of inducing hyperlipidemia, elevation of liver enzymes and onset of fatty liver disease. Like any other restrictive dietary plan, the ketogenic diet is often difficult to maintain long-term. Cycling in and out of ketosis reduces its metabolic effects.”

It must be said that this is the only research paper that I found which claimed that there is a negative effect of ketogneic diets on the liver. For instance, the following contradictory conclusion from a research paper also from NIH puts forward the premise that there is actually a mutually exclusive relationship between nonalcoholic fatty liver disease (NAFLD) and “hepatic ketosis”, which is the event of ketosis taking place in the liver:

“NAFLD affects nearly one-third of the population worldwide. The transition from simple steatosis to advanced stages of NAFLD depends on the accumulation of excess lipids due to an imbalance in lipid uptake and disposal. An essential lipid disposal mechanism, hepatic ketogenesis progressively declines as NAFLD severity worsens. Recent studies demonstrate a causal role of impaired hepatic ketogenesis in NAFLD pathogenesis. Accumulating evidence suggests that hepatic ketogenesis alleviates simple steatosis and NAFLD progression. Therefore, defining the mechanisms of hepatic ketogenesis is of great interest in identifying novel therapeutic targets in metabolic diseases, particularly in NAFLD.”

In other words, the liver being able to go into ketosis seems to be able to alleviate at least the beginning stages of NAFLD, and where this paper is suggesting that further research can be done in this area. This finding stands in contradiction to the previous paper, and where it has often been the case that various sources either support ketogenic diets or are slightly negative towards them. This perhaps concurs with my own scepticism at times regarding whether a high intake of fat can really be considered to be safe, and where I have erred towards the first paper quoted in this section in terms of only consuming polyunsaturated fats instead of animal fats, especially since I am in my mid-40’s now and a former young Australian. Finally, here is an excerpt from Medicine Net which presents both sides of the argument:

“If you have existing liver problems, the keto diet can make them worse. Your liver breaks down fat and converts it to energy and cholesterol. A high-fat diet like the keto diet can cause fat to build up in your liver and lead to fatty liver disease.

Animal studies suggest the keto diet can cause nonalcoholic fatty liver disease, or NAFLD, and raise liver enzyme levels. However, other studies suggest that the ketones diet can improve NAFLD and lower liver fat content.

These are early animal or human studies that show early results, though. More research is needed to understand how or if the ketones diet produces long-term results.”

Given these conflicting opinions, the simple fact stands for myself that a ketogenic diet has at times presented the only effective way to lose weight without being the owner of a gym. In addition to this, even if I have a certain intake of high-fats while on a ketogenic diet, this would be nothing compared to if I was not on a diet at all and regularly eating pizzas while downing glasses of sugar-saturated soda. I think that health sources miss the bigger picture sometimes in having to be too careful with the information presented. Therefore, the question of there being a trade-off between being on a ketogenic diet, which might have health risks, compared to being overweight is perhaps overplayed, although I would agree with some health sources that someone going for a higher intake of animal fats would most likely be taking a health risk, ie. if I would appear to be arguing in favour of a ketogenic diet, then this would only be with regards to a diet of polyunsaturated fats compared to visiting an Australian-themed steak house five nights a week in order to lose weight.

The main points regarding a ketogenic diet can now be expanded. Indeed, our knowledge base must grow!:

a damaged liver will have more difficulty burning fat as a fuel source.
the evidence is still out regarding whether a ketogenic diet benefits or harms the liver, ie., it might be the case that a ketogenic diet can reverse liver damage, or that it can make liver damage worse through more fats being consumed. More research is required
the question regarding a ketogenic diet having a high-fat content that negatively impacts the liver can be mitigated by consuming polyunsaturated fats, such as the fats from plant products, instead of consuming animal fats (and where this is my own approach).
it is my own opinion that I would consume more fats from food if I was not on a ketogenic diet at all, thus rendering a lot of the arguments about a higher fat-intake while on a ketogenic diet as being redundant.

Can the brain really run on ketones instead of glucose?

There is a common theme with most of the dietary sources that I have researched in that it is always stated that the brain requires glucose to function. This reason that this is relevant for a ketogenic diet is because the brain cannot make its own glucose, and where the inference is that a certain level of glucose needs to be maintained in order for adequate brain function to be supported. This is perhaps stated often because there isn’t any extensive research yet on the long-term effects of the brain running primarily on ketones. However, in digging just a little deeper it was found that there are some questions being asked about the long-term therapeutic effects of ketones for the brain, and specifically in the context of neurogenerative disorders such as Alzheimer’s disease. A research paper from Science Direct provides the following information:

“To meet its high energy demands, the brain mostly utilises glucose. However, the brain has evolved to exploit additional fuels, such as ketones, especially during prolonged fasting. With aging and neurodegenerative diseases (NDDs), the brain becomes inefficient at utilising glucose due to changes in glia and neutrons that involve glucose transport, glycolytic and Krebs cycle enzyme activities, and insulin signalling. Positron emission tomography and magnetic resonance spectroscopy studies have identified glucose metabolism abnormalities in aging, Alzheimer’s disease (AD) and other NDDs in vivo. Despite glucose hypometabolism, brain cells can utilise ketones efficiently, thereby providing a rationale for the development of therapeutic ketogenic interventions in AD and other NDDs.”

It seems to be the case that while the brain just plain wears-out with aging, that this event might be likened to glucose burnout in the brain cells just as much as to any neurodegenerative disease. This is interesting in that while most health sources mention that the brain needs glucose, such information of course does not take the effects of aging into account. What is being put forward in the paper just quoted is that if the brain of someone with a neurogenerative disease can switch from glucose to ketones for its energy supply, then this switch can perhaps bypass at least some neural damage in the brain cells pertaining to glucose burnout. For instance, the same paper in its conclusion states:

“Preclinical and limited data suggest that boosting ketone levels has therapeutic potential for these diseases, although the mechanisms by which this strategy may be effective are not completely understood.”

Another research paper from Frontiers in Nutrition investigates the same themes:

“The ketogenic diet (KD) is a high-fat low-carbohydrate diet that has been used for decades as a non-pharmacologic approach to treat metabolic disorders and refractory paediatric epilepsy. In recent years, enthusiasm for the KD has increased in the scientific community due to evidence that the diet reduces pathology and improves various outcome measures in animal models of neurodegenerative disorders, including multiple sclerosis, stroke, glaucoma, spinal cord injury, retinal degenerations, Parkinson’s disease and Alzheimer’s disease. Clinical trials also suggest that the KD improved quality of life in patients with multiple sclerosis and Alzheimer’s disease. Furthermore, the major ketone bodies BHB and ACA have potential neuroprotective properties and are now known to have direct effects on specific inflammatory proteins, transcription factors, reactive oxygen species, mitochondria, epigenetic modifications and the composition of the gut microbiome. Neuroprotective benefits of the KD are likely due to a combination of the cellular processes and other potential mechanisms that are yet to be confirmed experimentally.”

It can then be discerned from this passage that most health sources are cautious with their information about ketones since the science has still not been investigated. For example, it is suggested in this paper that not only might a ketogenic diet be beneficial for brain and nerve cells, but where it might be the case that there are additional neuroprotective properties regarding how ketones interact with such cells, and where science has still not caught up to this proposition yet with the backing of full research. However, while speaking of being cautious, the conclusion of the same paper states the following:

“Therefore, although adverse effects of the KD are minimal, evidence does not yet indicate adopting the KD for reducing neurodegeneration in common neurological diseases.”

It is interesting that this paper began with such optimistic hopes, but then reached a rather flat conclusion which, it might be said, is based on there being a lack of evidence since “results from larger randomised clinical trials have not yet been reported”. Yet perhaps the most relevant point here is that the long-term effects of a ketogenic diet are unknown since there is not yet a sufficient amount of research from any long-term trials. However, if it were to be demonstrated that a ketogenic diet could improve neurodegenerative disorders like MS or Alzheimer’s disease, then it would most likely be the case that the diet as a form of therapeutic treatment would need to be a more or less permanent proposition. Furthermore, as I mentioned before, if someone was stranded on a tropical island for 2 years and only had wild tomatoes, lettuce, maybe some goat’s milk (as long as the goat could be caught, the stranded person would have all day), and a variety of fruit trees for sustenance, which is effectively what a ketogenic diet can be regarding the low-carbohydrate and low-sugar content of all of these foods, then I would hardly think that this person would be diagnosed as being overly unhealthy at the end of such an ordeal. In addition to this hypothesis, indigenous people essentially lived on nothing but a ketogenic diet for generations before being forced into eating fast-food after colonisation. Therefore, there might be something of the esoteric versus the orthodox regarding the proposition of a ketogenic diet for the long-term, and where as mentioned the science still seems to be out on this topic.

Do ketogenic diets pose a cardiac risk?

Ironically, while researching this topic of any cardiac risks from being on a ketogenic diet, I came across an article from Penn Medicine summarising what I have just mentioned previously:

“The truth is, while the little-to-no carb, high-fat diet can dramatically help shed pounds, there haven’t been any long-term, randomised clinical studies to help determine the long-term effects on the body. Most studies to date are smaller scale, and they’re filled with both positives and negatives. Some suggest it improves blood sugar in diabetics and lessens cardiovascular risk factors, like obesity. Others report spikes in ‘bad’ cholesterol, heart problems, and hypoglycaemia. To add to the uncertainty, its effectiveness as a weight loss treatment hasn’t even been clinically proven, experts have said. What’s left is anecdotal evidence and people from all corners of the web - including physicians, nutritionists, and celebrities - raving or ranting about it.”

Once again, the truth about a ketogenic diet might be hidden behind the mentality of people wishing to wait for an expert to tell them that the sky is blue, although anyone can see this by looking outside on a clear day, but where at the same time there might be real risks to the diet which are as of yet unknown. The pros and cons definitely need to be weighed up on the issue, but where there is a lot of leeway regarding ketogenic diets and their possibilities. However, these possibilities, whether they might pan out or not, are perhaps completely dependent on the experience of the individual at this point in time until the science catches up. As mentioned, indigenous people might be the best alternative to a clinical trial here, especially if a person can find a tribe in the Amazon or some such place with significantly lower rates of neurodegenerative disease - not that I’m expecting any of my blog readers to literally follow through with that mission!

Yet in having said all of this, and once again where I find it better to err on the side of caution by keeping away from animal fats (in favour of polyunsaturated fats) with my own diet, there is indeed some evidence provided by the American College of Cardiology that a ketogenic diet can lead to high cholesterol levels:

“The ketogenic or ‘keto’ diet, which involves consuming very low amounts of carbohydrates and high amounts of fats, has been gaining popularity. However, a new study presented at the American Cardiology’s Annual Scientific Session Together With the World Congress of Cardiology suggests that a ‘keto-like’ diet may be associated with higher blood levels of ‘bad’ cholesterol and a twofold heightened risk of cardiovascular events such as chest pain (angina), blocked arteries requiring stenting, heart attacks and strokes.”

These guys sound like real heavy-hitters! The study on which this information was based involved analysing data from the UK Biobank which is a database that could follow people’s health information for over 10 years, and which involved the data of half-a-million Brits. The findings were as follows:

“Compared with participants on a standard diet, those on an LCHF [low-carb high-fat] diet had significantly higher levels of both LDL cholesterol and apolipoprotein B (apoB), the protein component that sits on LDL and other atherogenic lipoprotein particles. Previous studies have shown that elevated apoB may be a better predictor than elevated LDL cholesterol for risk of cardiovascular disease, Iatan said. After an average of 11.8 years of follow-up - and after adjustment for other risk factors for heart disease, such as diabetes, high blood pressure, obesity and smoking - people on an LCHF diet had more than two-times higher risk of having several major cardiovascular events, such as blockages in the arteries that needed to be opened with stenting procedures, heart attack, stroke and peripheral material disease. In all, 9.8% of participants on an LCHF diet experienced a new cardiac event, compared with 4.3% of those on a standard diet, a doubling risk for those on an LCHF diet.”

At the same time, the nature of a ketogenic diet depending on the individual comes into play:

“‘On average, cholesterol levels tend to rise on this diet, but some people’s cholesterol concentrations can stay the same or go down, depending on several underlying factors,’ Iatan said. ‘There are inter-individual differences in how people respond to this dietary pattern that we don’t fully understand yet. One of our next steps will be to try to identify specific characteristics or genetic markers that can predict how someone will respond to this type of diet.’”

It then seems to be the case that the success of a ketogenic diet, at least for any given individual, might depend on factors that are still waiting to be discovered experimentally. I have also refrained from including quotes from any other sources which claim that ketogenic diets actually lower LDL, or “bad” cholesterol, since I don’t wish to discredit anyone in this blog (although one of the previous quotes in this blog actually makes such a statement). Suffice it to say, I don’t actually endorse the type of ketogenic diet which involves someone buying a barrel of pork chops for their nightly meals. I think that consuming any kind of fat that congeals on a plate is a dubious proposition, let alone in deliberately consuming more of it for the sake of generating ketones. Yet at the same time, someone who is obese would most likely already have a problem with high-fat content not so much on the plate, but within their own system, and where a healthier variant of the ketogenic diet might have more advantages in terms of weight loss occurring if that is the easiest option. Therefore, while the science is still controversial, experience tells me that a moderate ketogenic diet is still a good idea for getting out of a jam (Homer Simpson moment - Mmmm, jam).

Ketones and muscle mass

It struck me that during the process of the body going into ketosis, that any remaining glucose is extracted from the liver and muscles, and that there is a temporary break-down of the muscles during this process. This wouldn’t sound good for someone who wishes to maintain muscle mass while losing weight. Indeed, having muscle mass is also important for maintaining a high level of metabolism (see the blog “Prepping for weight loss 02 - Know your metabolism”). I then found a fitness site called HMVN which supports the idea that a ketogenic diet not only does not necessarily lead to a loss of muscle mass, but might even contribute to it:

“Fail to eat enough protein, the saying goes, and you’ll shrivel up, lose muscle, and go frail. This fear is instilled by people who say that keto doesn’t contain enough protein to maintain lean muscle mass.

However, research shows exactly the opposite - that the ketogenic diet actually prevents muscle from being broken down. When an equal number of calories are consumed on diets containing the same amount of protein but differing levels of carbs, the lower-carb diets actually maintain lean muscle mass to the greatest extent.

Ketosis might actually improve our ability to utilize proteins. This could be due to the fact that the body no longer needs to breakdown protein for gluconeogenesis—instead utilizing ketones, sparing the protein we have. Studies support this. During ketosis and infusion of ketone bodies, it is shown that the utilization of BCAAs for energy is reduced, leading to enhanced protein synthesis and muscle maintenance.

Not only do ketones spare protein for muscle maintenance, but they actually can significantly increase muscle protein synthesis. Athletes who ingested a ketone supplement made of a BHB monoester had increased activity of mTOR, leading to a doubling of protein synthesis.”

While there are a few technical terms here, what is basically being said can be clearly discerned. This brings the discussion once again back to the notion that although there are controversies regarding the ketogenic diet, at least the really high-fat version, that there is something else going on regarding its benefits, and that these benefits are still being explored. The same article also mentions:

“Given it’s advocacy of extremely low carb intake, the keto diet has been advised against by many in the bodybuilding and sports performance world. The idea that carbohydrates are necessary to induce muscle growth probably came from the fact that insulin and IGF-1, which both rise in response to carbohydrate intake, also stimulate muscle protein synthesis.

Furthermore, many recommendations exist that tell athletes to consume protein plus carbohydrates in the post-workout window to really maximise gains and promote recovery. Again, the thought is that the carbohydrates will stimulate insulin, promoting a greater amount of muscle protein synthesis than protein alone.

However, when studies compare protein ingestion alone to a combination of protein and carbs after resistance exercise, there is no difference in muscle protein synthesis. Long story short: the carbs don’t seem to be adding anything extra. This is probably due to the fact that the amount of protein ingested is enough to raise insulin levels and activate mTor. More insulin doesn’t necessarily mean more protein synthesis, in this case.”

What is interesting is that high amounts of protein are not advisable on a ketogenic diet since protein converts into glucose. However, the context of bodybuilding would obviously be different since protein is required for muscle protein synthesis following workouts. It then seems to be the case that in a post-workout context this article is arguing that an intake of carbs might be relatively redundant, and that only an intake of protein might be required in such instances. Therefore, while an ordinary ketogenic dieter would most likely need to limit their protein intake, for someone wishing to retain muscle mass following workouts an intake of at least some extra protein would be required. It is then compelling to consider that not only might a ketogenic diet be beneficial for the maintaining of muscle mass, but where it could be the case that, if the intake of proteins is managed effectively in the context of working out, that muscle protein synthesis can potentially become doubled. So much for the ketogenic dieter having sand kicked in their face at the beach!

Many of these most recent points can now be added to our catalogue of ketogenic diet knowledge:

a ketogenic diet deprives the body of glucose.
glucose is obtained by eating carbohydrates.
glucose is not just a form of sugar but contains many vitamins and minerals that are essential for nutrition.
weight gain is more attributable to a high intake of calories rather than to a high intake of carbohydrates.
when there are no more dietary carbs, the body pulls glucose from the liver and muscles until it is depleted.
since the role of insulin is to transport glucose into the cells, insulin decreases when glucose is depleted.
the liver produces ketones from stored fat as an alternative source of energy.
proteins might prevent ketosis since they convert into glucose.
whether a person can go into ketosis quickly depends on their amount of body fat and resting metabolic rate.
about 80% of a ketogenic diet involves an intake of fat.
from one’s own experience, ketosis and weight loss can occur without consuming animal fats.
a damaged liver will have more difficulty burning fat as a fuel source.
the evidence is still out regarding whether a ketogenic diet benefits or harms the liver, ie., it might be the case that a ketogenic diet can reverse liver damage, or that it can make liver damage worse through more fats being consumed. More research is required
the question regarding a ketogenic diet having a high-fat content that negatively impacts the liver can be mitigated by consuming polyunsaturated fats, such as the fats from plant products, instead of consuming animal fats (and where this is my own approach).
it is my own opinion that I would consume more fats from food if I was not on a ketogenic diet at all, thus rendering a lot of the arguments about a higher fat-intake while on a ketogenic diet as being redundant.
switching to ketones as an energy source might be able to bypass damage to nerve cells, including brain cells, which are no longer receptive to glucose.
although it has been suggested that such a diet might be able to lessen the symptoms of neurodegenerative disorders, the long-term effects of a ketogenic diet might either be beneficial or harmful.
there is evidence that ketogenic diets might double the risk of cardiac events such as strokes and heart attacks, although there might be undiscovered individual genetic factors that contribute to these risks.
when combined with higher levels of protein intake following workouts, a ketogenic diet may have the potential to double the amount of muscle protein synthesis.

As can be seen, there is a pattern in all of these points that oscillates between the potentially beneficial and the potentially harmful effects of a ketogenic diet, and where it is perhaps the case that undiscovered genetic factors might be at play that would decide the outcome of a ketogenic diet as either being positive or negative, along with there being variations within the ketogenic diet itself, such as in consuming polyunsaturated fats versus animal fats, working out while consuming more protein and so forth, that might be able to reduce any negative health factors while enhancing the sometimes vastly beneficial side of this type of diet.

Conclusion

During this blog I have gone beyond considering “ketogenic” as a buzzword and have looked at the mechanisms by which such a ketogenic diet operates. It was then discovered that a ketogenic diet changes the energy source which the body uses from glucose, as derived from carbohydrates, to fat as derived from ketones through the process of restricting the intake of carbohydrates. When on a ketogenic diet, the body actually consumes its own fat which is quite handy for an overweight person, and which can lead to up to 5 times the amount of weight being lost than on a low-calorie diet. It was also discovered that rather than being a diet involving lots of proteins, that proteins themselves can convert into glucose and might not be advisable. The premise that a ketogenic diet involves as much as 80% of the menu being fats, whether these be animal or polyunsaturated fats, was then introduced.

It was then explored about how carbohydrates are not to be confused with calories, and where carbohydrates, along with proteins and fats, have nutritional components which are vital to health. At the same time, it is also the case that fats contain important vitamins and minerals, and are not just nutritionally empty calories as might be suspected. From this perspective, the emphasis of the article then turned to the role that the liver plays in a ketogenic diet, and where I became somewhat sceptical about whether a high fat-diet might benefit or harm a liver that already contains a dangerous number of fat cells. It seems that the jury is still out on this question due to ketogenic diets still being a new area of research.

The topic was then explored of whether the brain can run on ketones for the long-term. This proposition is at an interesting crossroads since while the current science must maintain that the brain requires glucose in order to function, it has been found that switching the brain’s energy source to ketones can bypass a lot of glucose burnout in brain cells, particularly regarding neurodegenerative disorders such as Alzheimer’s disease. However, it was found that researchers still need to maintain a cautious position regarding the effectiveness of a ketogenic diet in mitigating the symptoms of neurogenerative disorders since the research data is simply not available yet. Despite this otherwise incredible possibility of lessening the symptoms of debilitating illnesses, either the long-term or short-term effects of a ketogenic were then considered from the perspective of cardiac health, and where it was found that there might indeed be some red warning signals here as derived from a research project involving the data of half-a-million people in the UK. I then considered whether replacing animal fats with polyunsaturated fats would mostly mitigate this risk, and even put forward the notion that I myself would probably be consuming twice as much fatty food if I were not on a type of ketogenic diet at all. Furthermore, it was also found that there are likely undiscovered genetic factors that determine whether a ketogenic diet is beneficial or harmful to a person’s health. However, in having said this as someone on a long-term ketogenic diet myself, I have obviously not died yet and cannot state what my own cause of death might be - whether this be by hamburger or by avocado.

Finally, although I only exercise about once a year (only joking, sometimes just walking between houses in the outback can feel like a mile), I found some interesting research that not only does a ketogenic diet not necessarily lead to muscle loss as might be believed, but where bodybuilders using a ketone supplement were found to have doubled their level of muscle protein synthesis compared to other bodybuilders consuming high amounts of carbohydrates after a workout. Yet as usual, all of the research is still to be done regarding what the benefits of ketogenic diets might actually be.

In summary, a pattern was observed when researching for this blog where articles about ketogenic diets had a tendency to be polarised, ie. either the article would be saying nothing but positive things about a ketogenic diet, or where the diet was being made to sound ominous due to its emphasis on consuming a high intake of fats, along with the scarcity of long-term data for such a diet being alluded to. It is then perhaps not so much a case of the ketogenic diet being controversial, but where even though it has been popular for a decade or two there still hasn’t been an adequate amount of research study to be able to say comprehensively what its effects are. This is interesting since there are variations that can be made to a ketogenic diet to mitigate some of its health risks, along with this diet essentially still being a new frontier which can have perhaps incredible benefits for the brain and nervous system beyond its current modality of being just to lose weight, and lots of it.

Researching for this blog has been one of those events of thinking that everything has been in the bag regarding knowledge about a particular topic, but only to find that the possibilities are still open about the true effectiveness of a ketogenic diet. Having said this, I really hope you have enjoyed the article. Youmusteat.com provides both a series of informal blog posts about dieting as well as some medical articles covering key health issues related to dieting and to health in general. Please feel free to visit the blog page as well as to provide any feedback to admin@youmusteat.com

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