Laura Roche RD Horizon Health Authority May 29, 2018
AGENDA History of the Ketogenic Diet Diet Pathophysiology Side Effects Pros and Cons How and Why the Diet works Ketogenic Diet for Type 2 Diabetes Ketogenic Diet in Cardiovascular Disease Who is the Diet appropriate for Conclusions
HISTORY OF THE KETOGENIC DIET Originated in the 1920s after starvation studies discovered that after several days without food seizure activity stopped. Then discovered that the same results could be produced by introducing an extremely low carbohydrate diet (<20g/day) to induce ketosis. Was initially used to treat epilepsy. Diet lost popularity with the discovery of anticonvulsants.
TYPES OF KETOGENIC DIETS The standar ndard d Ket etogen ogenic ic diet et is tradi aditionally tionally 75-80% Fat, , 15 15-20 20% Protein ein and 5% Carboh bohydrat ydrate. Various ious adaptat tations ions of the ket etogen ogenic ic diet et are now used since nce the Ket eto o Diet et became me so popular lar. . Cyclical (5 days Keto then 2 higher carbohydrate days) Targeted (Standard Keto but with carbohydrates surrounding workouts)* High Protein Keto (60%fat, 35% protein, 5%carbohydrate)* Fad Diets ( Atkins, Modified Atkins, Paleo, Dr. Poon , etc) Not ote: Targeted and High Protein Keto are designed more for athletes and body builders
PATHOPHYSIOLOGY (HOW KETO WORKS) Ketosis can be induced either through fasting or drastically reducing ones carbohydrate intake. Ketosis is our bodies survival mechanism during periods of starvation. Lack of Carbohydrate leads to depleted glycogen stores which prevent oxaloacetate (made primarily from glucose) from normal fat oxidation in the Krebs Cycle.
PATHOPHYSIOLOGY (HOW KETO WORKS) After 3-4 days of fasting or extremely low carbohydrate intake our body enters ketosis and people experience “brain fog” or “keto brain”. The three ketone bodies produced by the liver are: Acetoacetate (AcAc), Beta-Hydroxybutyric acid (BHB) and Acetone. The liver is unable to use these Ketone Bodies as energy (BHB AcAc Ac-CoA Krebs Cycle)
PATHOPHYSIOLOGY (HOW KETO WORKS) 2 Pa Pathw thways ys of Gluconeogene oneogenesis sis Breakdown of Protein: Glucogenic Amino Acids (AA),Glutamine and Alanine that are stored in the muscles can be turned into glucose. Breakdown of Lipids: Glycerol -liberated from Triacyleglycerols (TAGs) First st few days to week of ket eto o is fueled ed mainly nly by Glucogen ogenic ic AAs. Once “Fat Adapted” keto is fueled mainly by Glycerol. Only 16% is fueled by glycerol during the first week of keto 60% once fat adapted, this is why you can preserve lean muscle mass relatively well.
PROS OF THE KETO DIET Better Blood sugar control and weight loss Better blood profile Reduce blood pressure Increased HDL Can be very effective with proper adherence More flavorful than many traditional diets Increased satiety Increased leptin and insulin sensitivity Most of these positiv tive e side effects s can all be s side effects s of wei weight ht loss in general. l.
CONS OF THE KETO DIET Extremely restrictive Difficult to travel with Possible social isolation Only a temporary solution (not a long term diet) Potential side effects (Ie: disordered eating, false food beliefs) Medical complications (re-feeding syndrome) GI issues (constipation/diarrhea) Fatigue Possible Nutrient Deficiencies Ket etogenic ogenic Diet should hould reall lly y be co consider sidered ed a last st resor ort! t!
SIDE EFFECTS OF KETO A D A P T A T I O N P E R I O D L O N G T E R M Headache, Bad breath Decreased Cognitive Function Micronutrient Deficiencies Bad Breath Loss of lean muscle mass Weakness Fatigue Constipation or Diarrhea Dehydration Vitamin/Mineral Deficiencies
KETO VS “TYPICAL” WEIGHT LOSS DIETS Issu sues es Shor ort t Term rm Long g Term rm Fat loss Same as any other Same as any other calorie matched diet calorie matched diet Lean Tissue More lean tissue loss More lean tissue loss with Keto with Keto Anaerobic Performance Decreased compared to Not enough data other weight loss diets Aerobic Performance Decreased compared to Not enough data other weight loss diets Strength Performance Approximately the same Not enough data compared to other weight loss diets
WHY DOES KETO POTENTIALLY WORK Increase creased Therm ermic c Effect ect of Prot otei ein Targe rgeting ting Sati tiety ty Signal gnals/H s/Hormon ormones es Ket etone one Bodies es act as Appe peti tite e Suppres ppresants ants Long ng term rm optimi timized zed Fat Oxidati ation on Reductio uction n in Lipogen pogenesis esis and d increa creased ed lipol polysi ysis Simplic plicity ty in the e Guidel elines nes
MORE ABOUT SATIETY Shor ort t Term rm Long g Term rm Protein +++ +++ Fat + ++++ Carbohydrate + + Fiber ++ ++
WHAT IS KETO USE FOR? STRONG EVIDENCE: Type 2 CVD DM Epilepsy
WHAT IS KETO USED FOR? EMERGING EVIDENCE: Ac Acne Cancer er Neurol ologi ogical cal PCOS Disor order ders
TYPE 2 DIABETES Take e away y messa ssage ge: Not for Type I Diabetes Significant decreases in HbA1C, BG, TAG, LDL & BW Increase in HDL Still need a caloric deficit (>500kcal/day) No standard/Best Practice Guidelines to date Most studies cut diabetic meds in half (not insulin) Anywhere between20-100g CHO per day were used Still don’t know the optimal macro range How did studies confirm ketosis in subjects?
CARDIOVASCULAR DISEASE (CVD) Results of a RCT with 120 overweight, hyperlipidemic volunteers over 24 week period Test Group: <20g CHO, supplements, exercise & group meetings Control Group: Low Fat Diet (<30% fat, <300mg Cholesterol, 500-1000kcal deficit, exercise & group meetings.
RESULTS Ket eto Group Low Fat Group up Study Completion 76% 57% % Weight Loss -12.9% -6.7% Fat mass loss -9.4kg -4.8kg Lean mass loss -3.3kg -2.4kg Serum Triglycerides -0.84mmol/l -0.31mmol/l HDL 0.14mmol/l -0.04mmol/l LDL 0.04mmol/l -0.19mmol/l
CARDIOVASCULAR DISEASE (CVD) Ket etogenic genic Diet et can manipu ipulat late the blood lipid profile e very y well Can result lt in increased eased HDL and decr creas ease e in Triac acyl ylegly eglyce cerol ols s (TAGs) Gs) which is caus used ed by a decreas ease e in HMGCoA reduct ctase ase (which h is insul ulin in acti tivat ated ed) Can incre rease ase the size and volume me of LDL-C (collects ects everyt ything ing and expels it later r on) Does not ot result lt in decreas eased ed Renal l Functi ction on with individual iduals s with norma mal renal l funct ctio ion
LOOKING AT THE RESEARCH! How keto is defined? What amount of carbohydrate induces ketosis? How is ketosis verified? Currently, there is no standard protocol or guidelines for the ketogenic diet, thus each study uses their own definition of the ketogenic diet which makes assessment challenging. Not all studies have patients monitoring ketones or they are not all being monitored in the same way.
TESTING FOR KETONES Ur Urin ine e Stri trips ps – Acet etoac oacetat tate e (AcAc) c) Measures un-used Ketones Measured with Colours Not the most reliable test AcAc can be used very effectively once ‘adapted’ More reliable in the beginning Variab iables les Electrolyte and Hydration levels
URINE STRIPS Pros os Cheap and easy to administer Cons Not reliable long term, can get messy, decreased accuracy Must be consistent with timing and hydration
TESTING FOR KETONES Blood od Tests ts Blood Meter – Beta-hydroxybutyrate BHB = Transport Ketone Measured in mmol/L
BLOOD TESTS Pros os Most accurate measure Best for long term adaptation Cons More expensive/ invasive
TESTING FOR KETONES Breath ath Test st – Acet etone one Indirect measure (correlates to BHB) Measured in parts per million/ ppm
BREATH TEST Pros os Reusable device, non invasive Cons ns Indirect measure, takes longer to get a reading vs blood/ urine
WHO SHOULD BE CAUTIONED AGAINST KETO? Type I Diabetes Type II Diabetes on insulin, sulfonylurea's or SGLT2. History of disordered eating or eating disorder History of mood disorders History of GI disturbances Alcohol abuse Malnourished or at risk of malnutrition Children and teens Pregnant & Breastfeeding mothers
WHO SHOULD CONSIDER KETO? (AS A THERAPEUTIC APPROACH) Newly Diagnosed Type 2 Diabetes (not on insulin) Overweight and Obesity (no history of disordered eating) Overweight /Obese with Type II Diabetes or CVD
MONITORING CLIENTS ON KETO The decision to try a client on a therapeutic Ketogenic Diet should be made in consultation with the Registered Dietitian and their Primary Care Provider. Care should be shared between the Dietitian and Physician as: Medications may need to be adjusted by the Primary Care Provider Blood work needs to be monitored and interpreted correctly
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