Medical ketogenic diet bears burden of popularity despite being a useful therapy
The ketogenic diet is one of today’s most controversial diets. Celebrities and pop culture increasingly rave about low carbohydrate eating. Yet, some doctors and dietitians and the American Heart Association, are warning of dire consequences.
Surprisingly, the ketogenic diet is not new.
In fact, it has been used for over 100 years to treat childhood epilepsy. The ketogenic diet can reduce or stop seizures in many whose epilepsy did not respond to other treatments. The diet can work for people for whom numerous medications and even surgery had failed to control seizures.
Popularity brought many different versions of keto
Proven results for epilepsy and weight loss brought popularity, which gives rise to more versions of the “ketogenic diet.” Pop culture and the media have turned low carbohydrate eating into a weight loss trend. This popularity has brought great recipes and useful meal plans. Unfortunately, much of the popular integration of the ketogenic diet for weight loss and metabolic disease does not apply to the therapeutic version recommended in mental health treatment.
What is a ketogenic diet?
It is a high fat, low carbohydrate, moderate protein diet. A ketogenic diet results in the body and brain using fat instead of carbohydrates as its primary source of energy. In fact, “Ketogenic” implies production of ketone bodies from fat. The liver makes ketone bodies when carbohydrate intake is limited. It is these ketone bodies that are the fuel for the body and brain on this diet. It is the absence of carbohydrate fuel, glucose, that allows the diet to mimic the fasting state. Interestingly, fasting has been used to treat epilepsy since the time of Hippocrates and the Bible.
There are 3 types of ketone bodies: beta-hydroxybutyrate, acetoacetate, and acetone. These ketone bodies are measurable in blood, breath, and urine. This measurement capability allows clinicians and individuals the ability to objectively test for adherence and success with the diet. The degree to which ketones are present is the degree to which a person is in ketosis. Most adults lose weight initially, hence the current popularity of the diet. If they wish to, people can maintain weight or even gain weight while eating this way. For example, children with epilepsy can still grow while ketogenic. In fact, ketosis can be continued for the long term because weight can be maintained at a level appropriate for an individual.
Ketogenic Diet Variations
There are many variations of keto. Here are some:
- Classic Ketogenic Diet – 4:1 or 3:1 ratio of fat grams: protein + carbohydrate grams. This is the Medically Therapeutic Ketogenic diet
- Fasting, Intermittent Fasting, and Time Restricted Eating (12 to 24 hours between meals)
- Atkins Diet/ LCHF (low carbohydrate high fat)
- Modified Atkins Diet
- Ketogenic Diet- Calorie Restricted
- Low-Glycemic Index Treatment
- Diets enhanced by exogenous ketone supplements
- Ketogenic diet for weight loss. The Very Low Carbohydrate Diet (VLCD) limits carbohydrates to 20g a day. Other versions include a variety of carbohydrate and protein ranges.
- Ketogenic diet for performance for athletes and bodybuilders
Of course there are numerous websites, books, podcasts, and self-proclaimed experts. Those seeking a specific therapeutic outcome should depend on reliable medical sources.
Medical ketogenic diet as a therapeutic intervention
The version of the Keto diet that appears to work for serious psychiatric disorders is the strict medical version. (3:1 or 4:1 ratio of fat grams: protein + carbohydrate grams). This is the same one used in treating pediatric epilepsy. It is also sometimes referred to as a therapeutic dietary intervention. Others prefer to call it the very low-carbohydrate ketogenic (VLCK) diet, with 20g or less of dietary carbohydrates. Typically, deliberate restriction of kilocalories (kcal) is not recommended.
This version of the diet should be medically prescribed and monitored. That’s because it is very difficult to do and has serious risks, as well as potential benefits. Levels of ketones, glucose, electrolytes, and body weight all impact the diet’s effectiveness.
Additionally, medications often need to be repeatedly adjusted while in medical ketosis. For example, symptoms change and new side effects can emerge when people are in ketosis. Some medications can interfere with the effectiveness of the ketogenic diet. They do this by increasing blood glucose levels and preventing ketosis. In some cases medications may need to be safely reduced or stopped by a healthcare provider. Adjusting medications can sometimes be very dangerous. So it should only be done with medication supervision and monitoring.
Where do we get quality information on keto for mental health?
See our Keto-for-Psych resources page.
Starting the ketogenic diet can be very uncomfortable, and have medical complications requiring oversight.
In the first month of the diet people can experience:
- Keto – adaptation symptoms that are severe enough to be aptly called “keto flu”
- hypoglycemia, especially in diabetics on medications
- low blood pressure, particularly in those on antihypertensive medications
- weakness, dizziness, and other worrisome symptoms, which all need to be monitored and safely managed by a skilled medical team
Finally, treatment includes more than just the diet. Medications, electrolytes, sleep, daily routine, exercise, therapy, stress management, drug and alcohol use will all interact and affect the treatment efficacy. Consider timing your start for a period during which you can afford to miss work or school. Your initial adaptation symptoms may temporarily make it hard for you to function optimally. Adaptation often includes a short-term increase in hunger, so you may also appreciate having plenty of keto-friendly foods already prepared. For example, have an egg or tuna salad ready made for easy snacking.
Diabetes treatment with keto follows a parallel path
Virta Health is a virtual diabetes treatment clinic. When using a ketogenic diet to treat Type 2 Diabetes, Virta also finds close medical supervision appropriate.
“Many patients require multiple medication changes in just the first few weeks of starting Virta, and how this is done is highly individualized… Even assuming perfect adherence to the nutrition intervention, patients also differ greatly in their degree of insulin resistance, amount of internal glucose production (gluconeogenesis), and the complex interactions among multiple medications. There is no “one size fits all” approach, and there is a high risk of adverse effects such a hypoglycemia or low blood pressure if patients are not closely monitored during this transition.” (1)Virta Health, July 2019
Dangers of implementing the ketogenic diet for mental illness.
Patients…. please don’t do this on your own!
Carbohydrate withdrawal, fat-adaptation, and the keto flu all describe the initial period of adaptation to the Medical Ketogenic Diet. In the first few weeks of the ketogenic diet, symptoms might worsen as the body adjusts to using ketones as its primary energy source.
The initial period can be especially dangerous for people with serious mental illness. We can see insomnia, increased depression, suicidality, mania, and increased psychosis. While these usually pass in a matter of weeks, they need to be safely managed. Hypomania and mania are common, and often unrecognized by the patient.
Psychiatric medications can interfere with the diet’s effects and prevent recovery. But, they are difficult and dangerous to reduce or stop even with careful titration. All these factors underscore the need for medical supervision.
How do I create my own team?
Our best advice at this point is to work with your a competent mental health clinician.
You can discuss this therapeutic approach with your current clinician and see if they are willing to consider this type of intervention. You might even provide them with articles and bibliographies from this website.
If your mental health clinician doesn’t yet know about ketogenic dietary therapies, then we strongly recommend also collaborating with a ketogenic nutrition specialist. Many people work with a team of professionals to put this type of treatment together.
If you take any medications please include a competent prescriber on your team. E.g., a psychiatrist or your general practitioner who is familiar with the underlying illness and treatment goals.
Where do I find a Keto healthcare provider or dietitian?
While the Internet brings us a great deal of information for free, curating quality information and tailoring it to your individual circumstances takes skill and training.
Clinician referrals can be found on our Keto-for-Psych Clinicians page. You might get lucky and find one locally. Some will work with patients or consult remotely. At present, demand often outstrips supply, especially in keto for psychiatry. While it is frustrating to wait for medical care to change, in the meantime you can educate yourself and your doctors.
Possible medical indications
The list of possible medical indications for this diet keeps expanding. There have been published studies or case reports of a beneficial effect of the ketogenic diet for the following conditions:
- Alzheimer’s disease
- Amyotrophic Lateral Sclerosis (Lou Gehrig’s disease)
- Bipolar disorder
- Brain tumors
- Diabetic nephropathy
- Metabolic syndrome
- Migraine headaches
- Mitochondrial disorders
- Multiple sclerosis
- Neurological-metabolic disorders
- Parkinson’s disease
- Schizophrenia and schizoaffective disorder
- Traumatic brain injury
- Weight loss / obesity
Our blogs provide an evidence-based discussion of how the ketogenic diet may help these different disorders.
Is the ketogenic diet safe?
Contraindications include rare fat metabolism disorders and porphyria. Relative contraindications include pregnancy and breastfeeding, pancreatitis and kidney stones. If you have any medical condition, then please work closely with your healthcare providers.
Vitamins and supplements
The Medical Ketogenic Diet (4:1 version, or VLCK) of the diet may not provide enough of certain nutrients from foods. In some conditions, your body simply needs more of these. Your supplements should be guided by a competent doctor or dietitian. A multivitamin, sodium, potassium, and magnesium supplements are common. Calcium with vitamin D is also added in some cases.
What about all of that fat? Some say it is bad.
For example, these two organizations summarize the standard American diet.
American Heart Association summarizes conventional wisdom
The AHA summarizes conventional dietary wisdom in their Diet and Lifestyle recommendations as follows :
“Eat an overall healthy dietary pattern that emphasizes:
- a variety of fruits and vegetables,
- whole grains,
- low-fat dairy products,
- skinless poultry and fish
- nuts and legumes
- non-tropical vegetable oils
Limit saturated fat, trans fat, sodium, red meat, sweets and sugar-sweetened beverages. If you choose to eat red meat, compare labels and select the leanest cuts available.” (2)
US News & World Report ranking of diets (2019)
A panel of nationally recognized experts in diet, nutrition, obesity, food psychology, diabetes and heart disease ranked 40 popular diets. They ranked the Ketogenic Diet second to last in 2019. (3)
But … think again about cholesterol and what is safe
About 30% of people on a ketogenic diet have an increase in their LDL. However, not all LDL (low density lipoprotein) is the same.
- Small, dense LDL particles are a high risk factor for cardiovascular disease, and are increased with low-fat diets, but not usually with ketogenic diets
- Large, fluffy LDL particles are thought to possibly be benign, and are increased by diets high in saturated fat, like a ketogenic diet
LDL is not the whole story – HDL (high density lipoprotein, TG (triglycerides), glucose, and others are also important. These markers usually improve on keto. In fact, evidence of saturated fat causing heart disease is now being questioned (3). Prospective studies of the effects of the Ketogenic Diet on weight loss and diabetes show improvement in cardiac risk factors. (Except total LDL in some people.) However, it is important to understand that the final verdict about possible negative effects of a high fat diet has not been reached. Watch as research mounts and collaborate with knowledgeable clinicians to reach a decision about diet that fits you medically.
Low-carbohydrate eating moving mainstream.
For example, More Than 50 Doctors Call On The USDA To Overhaul The U.S. Dietary Guidelines, challenging the high carbohydrate paradigm currently promoted:
Call To Action For Guidelines to Benefit All Americans. They based their arguments on the following.
- Only 12 percent of the U.S. population is metabolically healthy
- 72 percent of Americans have a body mass index (BMI) in the overweight or obese range
- 52 percent have either diabetes or prediabetes.
- more than 20 percent of all healthcare spending in the U.S. is on obesity-related illness
- The ill-advised practice of recommending a one-size fits all approach to healthy eating irrespective of individual metabolic differences.
- National Academies of Sciences, Engineering, and Medicine (NASEM) calls for Redesigning the Process for Establishing the Dietary Guidelines for Americans
- American Diabetes Association’s (ADA) 2019 guidelines recognize a very low-carbohydrate eating pattern as appropriate and successful in controlling diabetes.
Check out our annotated bibliography of supporting sources for details.
Challenges of the ketogenic diet
- Research on the use of ketogenic dietary therapies is just beginning for most indicated medical conditions. As the body of research grows we’ll gain a better understanding of how, when and with whom it is best employed. Early results demonstrate that the ketogenic diet can be as powerful as a medication for some conditions.
- Unfortunately, most clinicians aren’t trained to implement and manage this prescription-strength intervention. Even so they can identify and treat related problems such as potassium, magnesium or iron deficiencies. They can run tests and apply their clinical training to tailor this intervention to each patient’s specific situation. People should work closely with a competent healthcare provider.
- Conflicting and false information is abundant in the popular media.
- As described above, there are many variations of the diet. Each has different indications and effects. A knowledgeable healthcare provider can give you information on which version might be right for you.
- The word diet hasn’t historically evoked the image of a powerful therapeutic medical intervention. Yet this diet can be as potent as medication for certain disorders.
- It has been shunned by many in the medical community, including physicians and dieticians. They fear fat, want to adhere to the U.S.D.A. dietary guidelines, and believe a diet can’t treat serious medical issues. This is because they do not understand ketosis and believe it to be dangerous.
Changing to keto takes some effort, but a good coach and quality resources ease the way
- Discouragement by the lay community often includes family, friends, co-workers, and acquaintances who view keto as a diet fad analogous to the grapefruit diet or any other passing dietary trend.
- Planning and preparing real food takes more time than eating highly processed foods. More time is required at the beginning as one researches recipes and ingredients. Even experienced cooks find they are learning new techniques involving higher fats and new ingredients for thickening and sweetening as they adapt their cooking and eating patterns. However, some advise that even fast food is acceptable on this diet e.g., a fast food burger without a bun will suffice if necessary.
- Finding appropriate foods when away from home can be difficult especially in the beginning. For example, learning to hunt through store shelves for cheese, hard boiled eggs, salami, pork rinds, jerky without sugar, as well as unsweetened nut and seed blends. Some restaurants offer lettuce wrapped burgers, chicken wings, and low carb options. Other proprietors will tell you frankly that there is sugar in every dish, so these restaurants may not be conducive to staying on plan.
Future research needed
Questions worthy of further investigation include:
- Does this diet really work for the “other” medical conditions listed above? If so, what is the effect, the size of the effect, and duration?
- Do individual diseases and disorders respond differently to variations of the ketogenic diet?
- What are its potential health-giving and disease-fighting properties?
- Are there adverse effects in some people? Do they continue once the individual is fat adapted?
- How long should people remain on this diet if it does work? For example, after a few years on the ketogenic diet some epileptics are able to increase carbohydrate intake without seizures. Others epileptics need to stay on it much longer.
- Is the diet safe over time, especially in treating chronic conditions? What are the implications of the elevated LDL (low density lipoprotein) phenomenon?
- How should we prioritize the ketogenic diet vs. other treatments in treatment algorithms?
- How do we motivate people to do this diet and make it easier to do?
Let us know if you want to participate with Chris Palmer, MD’s research going forward.
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We understand all too well the suffering of people with treatment-resistant mental illnesses. Current treatment approaches often are limited in effectiveness. Unfortunately they also come with cumbersome side effects. This website is our effort to curate information exploring metabolic and mental health connections. Our mission is to educate and promote evidence-based approaches.
Unfortunately, Dr. Palmer is not able to take any new patients or consultations. Our all volunteer team strives to bring you bi-monthly blog posts exploring the interface of mental and metabolic disorders. (We’d like to promise a weekly post, but we’re just 2 volunteers trying to keep up!) Please sign up for our weekly newsletter, email us your questions, and let us know what you find valuable. By reaching out you’ll be helping us help you.
Research & Sources:
- Why Medical Supervision is Necessary for Reversing Diabetes. Virta Health. July, 2019.
- American Heart Association Diet and Lifestyle Recommendations. June, 2019. https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/aha-diet-and-lifestyle-recommendations
- US News & World Report ranking of diets (2019) https://health.usnews.com/best-diet/best-easy-diets
- Bueno NB, Vieira de Melo IS, de Oliveira, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Cambridge University Press: 07 May 2013. DOI: https://doi.org/10.1017/S0007114513000548
- Taubes, G. Good Calories, Bad Calories. (2007).
- Bough, K. J. and Rho, J. M. (2007), Anticonvulsant Mechanisms of the Ketogenic Diet. Epilepsia, 48: 43-58. doi:10.1111/j.1528-1167.2007.00915.x [Of particular interest is the visual in Figure 4 of this publication.]