What is a Ketogenic diet: Advantages and Disadvantages:
Developed nearly a hundred years ago to treat epilepsy, the ketogenic diet is now offered in the management of overweight and type 2 diabetes.
Rich in lipids and low in carbohydrates, it goes to the ‘against nutrition recommendations.
While it has short-term benefits, its long-term health effects are not known.
Disrupting eating habits, causing digestive problems, it can quickly become difficult to follow.
 What is the ketogenic diet?
The ketogenic diet is a dietary mode in which the lipids (fats) provide most of the calories (70 to 80% or 90%) while the carbohydrates (sugars) are made in very small quantities (up to 10% of calories).
When the body is deprived of carbohydrates in this way, fat becomes its main source of energy (whether it comes from meals or is taken from reserves) and part of it is transformed into ketone bodies, hence the term “ketogenic”.
Ketones can be used as fuel for different organs, but they are mainly directed to the brain.
The ketogenic diet was developed in the early 20th century by Dr. Russel Wilder of the Mayo Clinic (Minnesota, USA) to treat epilepsy.
It represented an alternative to fasting – well known at the time to reduce epileptic seizures in both children and adults – by preventing weight loss and undernutrition.
It was widely used in this indication until 1938 when a new drug against epilepsy appeared.
Abandoned for several decades, it was prescribed again in the 1970s and especially the 1990s.
Today, it continues to be used, especially in pediatrics, in patients for whom anti-epileptic drugs prove to be ineffective. or in order to reduce the doses of these drugs (which have side effects).
In recent years, this diet has been proposed by certain nutritionists for the management of overweight and has been the subject of scientific publications in this indication.
It is also being studied for the treatment of type 2 diabetes, certain neurological diseases ( Parkinson’s disease for example), and certain cancers.
 How does the ketogenic diet work?
In a balanced diet, fat provides 35-40% of calories, carbohydrates 40-55%, and protein 10-20%.
The ketogenic diet, therefore, involves an upheaval in eating habits. It must also be followed very carefully (provide very little carbohydrate) to lead to the production of ketones and thus be effective.
When prescribed for epilepsy, the presence of ketone bodies in the body is regularly checked through urine tests.
The ketogenic diet causes profound changes in the body:
Ketone bodies – acetone (exhaled and imparting specific breath), acetoacetate, and beta-hydroxybutyrate – are not produced as part of a conventional diet providing carbohydrates (in the form of bread, starches, fruit, etc.).
However, ketone bodies, in particular beta-hydrobutyrate, seem to have a protective effect on neurons, in particular by exerting antioxidant activity.
They would also have an anti-convulsant action, which would explain their interest in reducing epileptic seizures.
Laboratory studies also suggest that they prevent degeneration of nerve cells that produce dopamine, which has aroused the interest of researchers working on Parkinson’s disease (a neurological disease caused by dopamine deficiency).
Ketones also have an appetite suppressant effect, which contributes to the weight loss effect of the ketogenic diet.
This diet results in reduced insulin production.
This hormone, the synthesis of which is stimulated by the increase in blood sugar (blood sugar level), is used to regulate the latter, but also to store carbohydrates and lipids and to prevent the body from using fat reserves as a substitute. of fuel.
The ketogenic diet, which provides very few carbohydrates, is accompanied by low insulin levels, thereby mobilizing fat stores and burn them.
This is one of the reasons why it would be of interest in the management of overweight.
Indeed, some researchers attribute the global “obesity epidemic” to excessive consumption of ultra-processed industrial foods with a high glycemic index: whose carbohydrates are digested quickly and raise blood sugar too much (especially if they are concentrated in carbohydrates and if you eat a large portion) and therefore insulin.
The ketogenic diet is also being tested in the management of type 2 diabetes, the most common form of diabetes accompanied by insulin resistance (blood sugar remains too high because the insulin produced is ineffective).
 What can I eat?
(a) Recommended foods:
- The meat, including more fat: lamb chops, loin or ribs, entrecote of beef, chunks of lamb, pork, beef or veal stew (stews, blanquettes …);
- The birds, with their skin duck, turkey, chicken, chicken;
- The meats: hams, sausages;
- The fish, particularly fatty fish: herring, mackerel, sardines, salmon;
- The eggs ;
- The aged cheeses ;
- The nuts: Almonds, hazelnuts, walnuts, pistachios and other nuts, avocado, and olives;
The seeds rich in lipids: from chia, flax, pumpkin, sesame, sunflower …
Tofu and tempeh ( high protein soy products ).
- The fats are in generous proportion.
Butter, sour cream, and coconut oil are recommended daily since they are rich in ” short or medium-chain fatty acids”, lipids that promote the process of ketosis.
Canola oils and nuts are recommended for their omega-3 essential.
It is advisable to drink at least 1.5 to 2 liters per day, in order to compensate for the low water intake of food (in general, foods high in fat contain little water).
(b) Prohibited foods.
Prohibited foods are the main source of carbohydrates.
- Bread, rusks, and breakfast cereals;
- Starchy foods: pasta, rice, potatoes, semolina, corn, quinoa, sweet potato, pulses;
- The savory preparations paste: quiches, pizzas, pastries;
- Breaded fish or meat;
- The meals, soups, and sauces trade ;
- The sweet products: cookies, cakes, pastries, chocolate bars, candies, jams, honey, table sugar;
- The sweet drinks: soft drinks, fruit drinks, iced teas … and fruit juices.
It is possible to use a synthetic sweetener (aspartame, sucralose, stevia, etc.) to “sweeten” coffee or tea or make desserts in which the flour is replaced by ground hazelnuts or almonds.
(c) Foods to moderate.
Foods to moderate are foods with low carbohydrate content :
- The dark chocolate over 85% cocoa;
- Milk and plain dairy products: yogurts, fermented milk, and fresh cheeses: maximum one per day (they provide lactose, which is a sugar);
- Vegetables: maximum 150 g per meal;
- The fruits least rich in sugar: lemon, red fruits, papaya, watermelon: maximum 50 g (the equivalent of barely half a tray of raspberries) per day. Other fruits are not allowed.
 Is the ketogenic diet easy to follow?
(a) Cost of the ketogenic diet.
The ketogenic diet excludes cheap foods like grains or processed foods and favors more expensive foods like meats, fish, or nuts.
Its follow-up can lead to an increase in the budget devoted to food.
To limit expenses, we can bet on:
- Eggs ;
- The so-called third category beef, veal, lamb, reserved for long cooking (to braise or boil);
- Frozen or canned fish of the mackerel or sardine type;
- Nuts sold in bulk.
(b) Effectiveness of ketogenic diet tracking.
Effectiveness against epilepsy
The interest of the ketogenic diet in the management of epilepsy is well demonstrated.
About half of the children who are prescribed it see their frequency of seizures decrease, up to 50%.
Additionally, the ketogenic diet is associated with improved behavior, attention, memory, and academic progress, which may be related to the decrease in anti-epileptic.
The ketogenic diet is less used in this indication in adults.
The recent synthesis of 17 small studies (conducted on 3-87 patients) confirms that reduces seizures in responders (at least 50% and up to 9 0%) and suggests that improves mood and quality of life.
(c) Effectiveness for weight loss.
As long as you control energy intake, the ketogenic diet can help you lose weight.
The synthesis of 13 studies, bringing together a little more than 1,400 patients, concludes that the ketogenic diet is more effective, compared with a classic weight loss diet in which lipids provide only 30% of calories: after 1 year of follow-up, the weight loss achieved was almost one kilo.
In a similar study published in 2016, after 2 years of follow-up, people on the ketogenic diet had lost 12.5 pounds and 11.6 cm in waist circumference, while people on the conventional diet had lost only 4, 4 kilos and 4.1 cm waist size.
As with all weight-loss diets, the question of medium or long-term stabilization of the weight obtained arises.
In a study of 377 overweight or obese people followed for 1 year, the ketogenic diet helped lose an average of 12 pounds for the first 12 weeks, then stabilize the weight for the next 40 weeks.
But, for lack of enough studies and hindsight, researchers cannot say that the ketogenic diet can permanently shed extra pounds.
In addition, they lack data regarding its safety beyond 1 year.
According to a team of Italian researchers, the ketogenic diet is useful in reducing appetite and promoting the burning of fat stores.
But it should only be used for short periods (e.g. for 20 days), alternating with a diet.
Mediterranean type normal-caloric to consolidate the weight loss obtained.
They also stress the importance, to prevent weight gain, by reintroducing carbohydrates only gradually after a ketogenic diet.
(d) Interest in the management of type 2 diabetes.
The interest of the ketogenic diet in the management of type 2 diabetes is debated among researchers.
This type of diabetes is linked to insulin resistance, which results in low efficiency of the insulin produced by the body,
Therefore blood sugar remains too high, especially in the hours following meals.
In the majority of cases, insulin resistance is due to overweight localized in the abdomen.
For a majority of people with type 2 diabetes, treatment involves weight loss, which reduces insulin resistance and thus improves blood sugar control.
The ketogenic diet, which has been shown to be effective in losing weight at least in the short term, could be a good dietary strategy.
Since it provides few carbohydrates (less than 50 g per day), it is not at risk of ” increase blood sugar levels despite insulin resistance.
A study in Spain on a group of 90 overweight type 2 diabetics, men and women aged 30 to 65, compared it to a classic low-calorie diet.
After 4 months, the ketogenic diet group lost an average of almost 15 pounds, compared to just 5 pounds in the conventional diet group.
The glycated hemoglobin (HbA1c), control of blood glucose level during the 3 months before the assay has further decreased in the ketogenic group, from 6.9% to 6%.
According to some researchers, who have compiled the existing studies, low-carb diets (but not necessarily as low in carbs as the ketogenic diet) are the most effective in controlling blood sugar levels in type 2 diabetics.
However, the official recommendations of learned societies do not go in this direction.
The American Diabetes Association recommends maintaining at least 150 g of carbohydrate per day, while the French-speaking Diabetes Society recommends a carbohydrate intake representing 45 to 55% of calories.
A review of studies dating from 2018 on the subject, carried out by a group of American researchers, confirms that low-carbohydrate diets can better control blood sugar.
But that on the other hand high-carbohydrate and low-fat diets are more effective. to reduce cardiovascular risk factors (diabetes increases the risk of developing cardiovascular disease).
Overall, there is no consensus on the value of the ketogenic diet in the management of type 2 diabetes.
In the current state of knowledge, it is contraindicated in people suffering from heart, kidney, or hepatic (liver) diabetes.
(e) Interest in the treatment of Parkinson’s disease.
The ketogenic diet has recently been studied in the treatment of Parkinson’s disease (as an adjunct to medication).
In rodents, it prevents the degeneration of neurons that produce dopamine (the deficiency of which leads to the motor disorders observed in Parkinson’s disease).
While studies in humans are few and only involve small groups of patients, their results are encouraging.
The ketogenic diet appears to reduce disease progression, improve vocabulary access and memory, as well as non-motor symptoms, such as depression, fatigue, daytime sleepiness, or urinary disorders.
Researchers, who have just published a synthesis of existing studies (including studies with patients suffering from Alzheimer’s disease), confirm the interest of the ketogenic diet in the prevention of neurological diseases.
And the need to carry out studies on a larger scale.
They nevertheless point out that the patients concerned are generally elderly and warn against the risk of undernutrition that can be caused by the ketogenic diet (which suppresses appetite and encourages less eating ).
(f) Interest in the treatment of cancers.
The ketogenic diet is also being studied in the treatment of cancers.
These diseases are generally accompanied by insulin resistance, hindering the proper use of carbohydrates by the body and thus promoting weight loss and weakness.
In addition, since cancer cells consume large amounts of carbohydrates, the ketogenic diet could somehow “starve” them and promote their apoptosis (cell death). a rationale that is difficult to prove in practice.
In 2017, researchers from the National Food Cancer Research Network (NACRe), were interested in the impact of restrictive diets or fasting on cancers.
They point out that in most lab studies done in mice, the ketogenic diet helps reduce tumor growth.
They nevertheless conclude that: ” the available data are insufficient and do not provide any proof as to the interest of the ketogenic diet in the prevention of human cancers “.
Other researchers have compiled the studies testing the ketogenic diet on humans in 2018: they are few in number, are interested in different cancers at different stages of the disease.
Their heterogeneity does not allow to conclude a favorable effect of the ketogenic diet.
However, the available data are encouraging and should encourage larger studies to properly assess the impact of the ketogenic diet on cancer prognosis, nutritional status, and more generally the state of health of patients.
(g) Limitations of the ketogenic diet.
While it has been shown to be effective in treating epilepsy and likely in managing obesity, the ketogenic diet is difficult to follow.
It disrupts eating habits and excludes many foods from everyday life.
In the majority of cases, it causes digestive disorders: nausea, vomiting, diarrhea (linked to its high intake of lipids), or constipation (linked to its low intake of fiber: no cereals, few fruits, and vegetables).
Many people are therefore led to abandon it quickly despite its positive effects.
What type of exercise should accompany the ketogenic diet?
Doctors who developed the ketogenic diet almost 100 years ago to treat epilepsy weren’t particularly advocating accompanying it with exercise.
Nowadays, its follow-up in the context of weight loss could be supplemented by a program of physical activity aimed at moderating muscle wasting (which exists regardless of the weight loss diet).
However, caution must be exercised given its very low carbohydrate intake (priority fuels for muscle): there is a risk of hypoglycemia (excessive drop in blood sugar levels), in particular in amateur athletes 25.
It is, therefore, better to stick to gentle activities, such as walking, yoga, or pilates.
In contrast, in trained athletes who exercise endurance (medium intensity and long duration), some studies suggest that the ketogenic diet does not interfere with performance.
And that muscles are able to burn more fat than we never imagined a few years ago 26.
 Is this diet dangerous for health?
(a) Cardiovascular risk.
The impact of the ketogenic diet on cardiovascular risk factors has been the subject of several study reviews and is ultimately still quite poorly understood.
- Very high in fat, the ketogenic diet increases, at least in some people, the blood levels of total cholesterol and LDL-cholesterol (“bad cholesterol”).
- This effect has forced patients with epilepsy to discontinue the regimen, even when it was found to be effective in reducing their seizures.
- Recent studies suggest the opposite, finding a decrease in LDL-cholesterol and triglycerides, as well as an increase in HDL-cholesterol (“good cholesterol”).
- These contradictory results could be explained by the differences in the lipid composition of the diets studied. (some provide more saturated fatty acids, others more unsaturated fatty acids).
- In addition, the enzyme involved in the hepatic production of cholesterol (HMG-CoA reductase) would be less active under the ketogenic diet due to a lower insulin level.
- The ketogenic diet helps to lose weight, which goes in the direction of reducing cardiovascular risk. However, existing studies do not make it possible to know whether the effect on weight is lasting.
- Even if the results are sometimes contradictory, studies lean towards an advantage of the ketogenic diet to reduce insulin resistance, whether people who follow it have diabetes or not. This effect also goes in the direction of a reduction in cardiovascular risk.
- The impact of the ketogenic diet on blood pressure is poorly documented.
Overall, although its effects can vary from person to person, the ketogenic diet seems to reduce cardiovascular risk factors in the short term instead.
However, it is not certain that its favorable effects persist beyond 6 months to 1 year.
The compilation of 19 studies shows that after 2 years, the ketogenic diet is no more effective than a conventional diet in improving weight or cardiovascular risk factors.
Especially because of the difficulties patients have in dieting. long-term. Its long-term impact should therefore be the subject of longer-term studies.
Researchers recommend ensuring the quality of the lipids provided by the diet: moderate saturated fatty acids and favor unsaturated fatty acids.
In the current state of knowledge, the diet is not recommended for people suffering from hypercholesterolemia or cardiovascular disease (angina pectoris, arthritis, history of myocardial infarction or stroke, etc.).
(b) Blood sugar risk.
In the short term, the ketogenic diet can cause hypoglycemia (related to reduced carbohydrate intake) with fatigue and headaches.
It is contraindicated in type 1 diabetes. In the event of type 2 diabetes, it may possibly be monitored under medical supervision (provided that they have not developed cardiac, renal, or hepatic complications of diabetes).
There is a risk of hypoglycemia, especially when treatment includes sulfonylurea.
(c) Risks to the kidneys.
The ketogenic diet tends to acidify the urine and thus increase the risk of developing uric acid-based kidney stones.
This risk can be reduced thanks to good hydration and the consumption of carbonated water rich in bicarbonates with an alkalizing effect (Salvetat, Badoit, Perrier, etc.).
Due to its composition and especially if its protein intake is high, the ketogenic diet could have an unfavorable impact on kidney function.
It is contraindicated in chronic kidney disease (renal failure) or high blood pressure (which promotes kidney disease).
(d) Bone risk in children.
A failure to thrive has been described in some epileptic children following the ketogenic diet in the long term.
These bone abnormalities are linked to nutritional deficits caused by the diet. Their prevention involves a sufficient intake of protein and the prescription of calcium and vitamin D 1 supplements.
 Is it compatible with special diets?
(b) Vegan diet.
The ketogenic diet, which excludes grains and pulses, is not compatible with a balanced vegan diet.
Combining the two diets would mean eating only oleaginous fruits, seeds, oils, and vegetables and would cause multiple deficiencies, in particular in proteins, calcium, vitamins D and B12 …
(c) Gluten-free diet.
The ketogenic diet excludes the main foods that may contain gluten: cereals and processed foods (dishes, soups, sauces, etc.).
It is compatible with a gluten-free diet, provided you check the composition of certain products, such as cold cuts or ground steaks, in which gluten can be used as a texturizing agent.
(d) Low salt diet.
The ketogenic diet excludes major sources of salt: store-bought bread and ready-made meals.
It is compatible with a low-salt diet as long as you limit cold meats, cheeses, smoked or canned fish, canned vegetables, salted nuts, and cooking salt.
(e) Kosher diet.
The ketogenic diet is compatible with a kosher diet, as long as you consume kosher meat and stick to permitted meats and fish.
(f) Halal diet.
The ketogenic diet is compatible with a halal diet, as long as you consume halal meat, stick to authorized meats and avoid commercial products containing the additives E 120, E 471, and E 472.
 Are the contributions of this diet sufficient?
The macronutrient intakes of the ketogenic diet are very far from the recommended intakes.
|Contribution to Total Energy Intake in a Ketogenic Diet (1)||Contribution to total energy intake according to recommendations for the French or European population (2)|
|Lipid intake||70 to 80%||35 to 40%|
|Carbohydrate intake||5 to 10%||40 to 55%|
|Protein intake||10 to 20%||10 to 20%|
The consequences of such intakes on health in the medium or long term are not known.
For some researchers, high-fat weight-loss diets increase cardiovascular risks.
Excluding grains and severely limiting fruits and vegetables, the ketogenic diet lacks fiber, which frequently results in constipation.
In addition, fiber is one of the preventive nutrients for cardiovascular diseases and certain cancers and contributes to a good balance of the intestinal flora (many studies point to a link between unbalanced microbiota and increased risk of various diseases).
Due to the restriction in fruits and vegetables, the ketogenic diet also lacks vitamin C, beta-carotene, and polyphenols (compounds with antioxidant or anti-inflammatory properties.
Which cannot be found in food supplements only very partially since there are more than 2000).
Overall, the ketogenic diet does not provide enough protective nutrients (useful in preventing the most common diseases, such as cardiovascular disease or cancer) to be followed for the long term.
Its follow-up for a few months must be accompanied by food supplements prescribed by a doctor or advised by a nutrition professional.
 What type of meals does this diet offer?
Example of a typical day providing 1500 kcal
- Unsweetened coffee or tea (possibility of sweetener);
- 30 g (1 handful) almonds, walnuts, or hazelnuts;
- 50 g of red fruits: strawberries, raspberries, blackcurrants, currants …
Lunch and dinner:
- 50 g of raw vegetables (the equivalent of a small grated carrot), vinaigrette with 1 tablespoon of walnut or rapeseed oil;
- 120 g of meat or fish or 2 eggs: cooking with 1 tablespoon of rapeseed or olive oil;
- 100 g of cooked vegetables (1 small plate), with 20 g (2 teaspoons) of butter or 60 g (2 tablespoons) of whole crème fraîche.
To taste :
60 g (the equivalent of 1/4 of camembert) of cheese OR 30 g of cheese and 100 g (1 ramekin) of whole milk cottage cheese.
 Pros & Cons of the Ketogenic diet:
(a)Pros of the ketogenic diet:
- The ketogenic diet requires limiting processed foods and cooking at home (to avoid any trace of carbohydrates in store-bought foods), which is in line with current recommendations 30. At this level, it promotes the acquisition of good dietary practices;
- Thanks to the ketones, the ketogenic diet suppresses the appetite, which makes it easier to follow it for weight loss (in conventional weight-loss diets, hunger increases as you lose weight, which contributes to the ” yoyo effect” );
- The ketogenic diet offers the possibility of eating fatty meats or cheeses, which are generally considered to be of better taste quality since the fats carry the aromas.
- Some studies show an attraction to fat in overweight people, a taste which would explain their difficulties in following long-term weight loss diets low in lipids 6;
- Likewise, fatty substances present in large quantities avoid dishes that are too dry – as is the case in many weight loss diets – and allow you to vary the preparations: gratins, sauces (without flour), fried foods, etc.
(b) Cons of the ketogenic diet:
- The beginnings of the diet can be painful: hypoglycemia, headaches, fatigue, linked to the restriction in carbohydrates; nausea and bad breath, at least during the initiation of the process of ketosis;
- The diet excludes many foods, bread and starches, sweet products, and some fruits. It can become monotonous, frustrating, and quite quickly difficult to follow. It can probably cause eating disorders in some people;
- The ketogenic diet has many contraindications: hypercholesterolemia, arterial hypertension, cardiovascular diseases, type 1 diabetes, chronic kidney disease, liver diseases such as fatty liver or “fatty liver” (because it is the liver that takes care of it. make ketones), stomach ulcer, irritable bowel.
 Now the opinion of the expert committee:
Pr Antoine Avignon, diabetologist and nutritionist.
“Undeniably, this diet should improve blood sugar levels, but treating diabetes also means preventing cardiovascular risk, which this diet does not do at all.
It is a restrictive diet that is binding and contravenes all nutritional recommendations. health”.
Aurélie Guerri, dietitian nutritionist.
“It is a diet that allows you to lose weight but which, like many diets, removes a family of foods necessary for the proper functioning of the body: carbohydrates.
This diet can therefore lead to deficiencies in the long term. In addition, the ban on common foods such as bread, pasta, certain fruits … is very frustrating and desocializing.
This diet is based on a diet high in fat and low in carbohydrates, which creates bodies.
Ketones with an appetite suppressant effect and less fat storage. But this diet also causes bad breath and digestive disorders. This diet does not comply with official recommendations “.
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