With so many diets available, it can be hard for people to know which ones are appropriate to follow. One that has received a great deal of attention is a ketogenic diet. If your patient is considering a keto diet, it is important to know how to respond.
This is discussed in the JAMA Patient Page, “Ketogenic Diets,” written by Zhaoping Li, MD, PhD, professor of medicine and chief of the Division of Clinical Nutrition at the University of California, Los Angeles (UCLA), and AMA member David Heber, MD, PhD, an internist and founding director of the UCLA Center for Human Nutrition.
“A ketogenic diet restricts carbohydrate intake to less than 25 to 50 grams per day in an attempt to enhance tissues to use fat or ketones (acids produced by the liver) as fuel during caloric restriction,” says the patient page. “Ketogenic diets typically recommend that only 5% of calories come from carbohydrates, along with 75% from fat and 20% from protein.”
Foods to eat on a keto diet often include full-fat dairy products, meat and poultry, non-starchy vegetables, coconut and olive oils, nuts and seeds, avocado, olives and eggs.
Here’s what physicians can share with patients.
Keto diets may lead to weight loss in the short term. However, these diets may not be good for the long term. In fact, “long-term data on keto diets and cardiovascular, cancer and other chronic disease risks are lacking, and low-carbohydrate diets have been linked to increased mortality,” says the patient page.
“That's, in a way, a safety effect because if they quit after two weeks, you're not going to hurt yourself,” Dr. Heber said on a JN Learning module, “The Keto Diet: Advice for Patients.”
“We used to have these diets where people would just drink juice and water for three days and lose X amount of pounds,” he added. “It was a total scam because they would regain the water and salt, but nobody really hurt themselves.”
“If you're on a keto diet for a week or two, you'll live, but it may not be effective for you in the long term,” said Dr. Heber.
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In the 1920s, ketogenic diets were first used to treat diabetes. This was prior to the discovery of insulin. Additionally, these diets were “used to treat difficult-to-control epilepsy in children,” says the patient page. While keto diets can be considered for controlling blood glucose in patients with prediabetes and type 2 diabetes, they are also being promoted for weight loss.
“For patients with prediabetes or type 2 diabetes, limiting carbohydrates to 5% of calories can help control blood glucose if it contributes to weight loss and weight maintenance,” says the patient page. However, while keto diets may improve blood glucose in the short term, “there is inconclusive scientific evidence that these diets are superior to other weight loss regimens in the long term.”
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If a patient is committed to following a keto diet for the short term, it is important to recognize the side effects and risks. For example, it is common to experience fatigue during exercise. They might also exhibit poor mental energy, increased hunger, sleep disturbance, muscle cramps, constipation, nausea and stomach discomfort.
“Over the long term, a diet in which only 5% of total calories come from carbohydrates makes it impossible to obtain optimum amounts of antioxidant phytonutrients from fruits and vegetables,” says the patient page. “In the first two weeks of the diet, there may be significant increases in urine production and fluid shifts that may require adjustment of medications for hypertension, heart failure and diabetes.”
If a patient decides to follow a keto diet, it is important for them to report back on how it goes over the first couple weeks. However, it is also vital that they exercise to build muscle and remain active.
“When you're exercising, you may need to take some carbohydrate,” said Dr. Heber. “There are a lot of diets out there that are what they call keto-friendly or keto-light,” which allows a person to have extra carbs to help offset exercise demands.
“Maybe take in a little more protein, take in whatever your particular gram target is,” he said, adding that he would calculate the gram target and say, “Well, you need 75 grams of protein a day, and here's how you would get it meal by meal.”
After discussing what the patient has for all meals, Dr. Heber would recommend that around the time of exercise, the patient has a food containing carbohydrates , “because that'll keep your glycogen stores up while you're exercising, so you won't get fatigued.”
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Patients should be encouraged to consult their doctor before trying a ketogenic diet and should only make the change under the supervision of that physician or registered dietitian.