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Norman Swan: The day diet, the keto diet, shortened for ketogenic. It is recommended for a lot of things, from eliminating fat with torn appearance, going through the current weight loss or in the garden, to treating type 2 diabetes. I've a statement of interest It has been said, on the occasion, you understand, to go myself to the keto. You have to work and you have to spend a few days feeling … well, there is no other word to say, shit, before the energy rush is manifested. And yes, you lose weight, but at the expense of your friends running a mile from your breath. And you seem to have to break the ketosis before going to the gym, because you can not really work well aerobically or on weight without some carbohydrates. So when it comes to being torn apart, it's a pipe dream, because my six-pack still has a hard time making itself known and revealing themselves.
Whatever the case may be, you are tired of anecdotes and you have not listened to my health problems. What is the evidence on the ketogenic diet? It's a debate that can almost get people to blows. But some brave researchers from the faculty of medicine at New York University have had a serious look. One of them is Shivam Joshi.
Shivam Joshi: Low carb diets have been around for decades, and they have had many iterations. The latest version is the ketogenic diet, which focuses on a small amount of carbohydrates.
Norman Swan: How much is the prescribed diet low?
Shivam Joshi: Thus, the amount of carbohydrates can range from 5% to 10% of the calories consumed, so it is quite low.
Norman SwanSo it's basically the milk in your coffee every morning, that sort of thing.
Shivam Joshi: Yeah, maybe a little more. I'm getting into trouble when I say excluding fruits and vegetables that are all carbs because keto enthusiasts chase me with forks and that they say: well, we're allowed to have so many grams of carbs a day as long as they do not. do not quit ketosis, which is the biggest concern. So, it is true that they can have some carbohydrates but not too much because they are so without ketosis.
Norman Swan: And we should just explain what is ketosis because it goes from carbohydrate metabolism of energy to fat metabolism.
Shivam Joshi: Well, so when you stop using carbohydrates as a source of energy and start using fats, these can come from the fats consumed but also from the fats stored in the body. Thus, the use of these fats produces energy and, as a by-product, you get ketones that can also produce energy, but these ketone bodies are pathognomonic, although that they exist at another time in human processes, but the ketone body is very critical. for this diet, that's why they call it the ketogenic diet.
Norman Swan: And some people test their urine, but you can also smell it.
Shivam Joshi: Exactly, and you can even test it on the breath, people can test it in various ways if you want to have ketosis.
Norman Swan: Well, let's take three different areas, one is weight loss, one is type 2 diabetes, the other, whether it protects your heart or not, because it tends to be rich in fat because you have to get your calories somewhere. So let's take a look at weight loss, because intuitively, it makes sense, especially if you do not have a high ketogenic diet or more protein, you'll start burning fat around your abdomen. It seems logical.
Shivam Joshi: Yes, and that is one of the arguments for the scheme. But when you look at low carb diets in general, Sentinel's weight loss capacity lies in the fact that they limit the number of calories, which has been shown over and over again in many different types of diets. no matter what diet. And I think anyone who is in the arena of the diet knows it. You can have a diet rich in cookies, cakes and other unhealthy foods, but as long as you limit the number of calories, you will definitely lose weight. And many diets manage to lead to weight loss because they create rules, they are able to make their followers adhere to these rules or religiously adhere to diets.
Apart from this, the evidence suggesting that the metabolism is increased or that the ketogenic diet is unique in that it causes more weight loss than other diets, including fat loss, do not seem to take place . There are small benefits and pitfalls with the diet here, but overall, there does not seem to be any difference with any other diet.
Norman Swan: And is science fixed on that? Have good randomized trials been done to compare different diets?
Shivam Joshi: Is science settled? So, do we have an abundance of high quality randomized controlled trials in the long run? No, so science is not defined yet, and that's probably why this debate will be raging for months, if not years to come. However, we have enough data to suggest that this diet may not be better than other types of diets. For example, my co-authors and I wrote this article in JAMA Internal Medicine, and we quoted this 2013 meta-analysis by Bueno et al. It was a meta-analysis or a summary study of at least 13 randomized controlled trials. These randomized controlled trials ranged over a year or more. This study showed the difference in weight loss between those who followed a ketogenic diet and those who did not follow it. The ketogenic diet or control diet was only 0.9 kg, which is statistically significant but may not be clinically significant.
Norman Swan: What about type 2 diabetes? Again, diabetes is a problem where … especially type 2 diabetes, where you do not metabolize carbohydrates properly because of insulin resistance, and so, intuitively, it makes sense that you reduce your carbohydrates and switch to fat metabolism. help diabetes. What is the proof there?
Shivam JoshiSo we used the same study, and when you go back to this study, they also looked at diabetics and found no difference between glycemic control and glycemic control. Short-term studies seem to show benefits, especially short-term studies that are not randomized. In some studies, comparisons are unfair. In some of the published studies, if you look at them, they randomize two groups; they will have a group that follows the ketogenic diet and another group that does not follow a ketogenic diet and they will compare the group the best. But buried in the experimental plan that you will have with the behavioral interventions of the ketogenic diet. They will benefit from support in telemedicine, behavioral therapy, visits to a nutrition counselor, an exercise or something else that could also help with compliance with the diet. Prescribed food and also help people to have a healthier life. And this may reflect more the fact that people adhere to a diet than the ketogenic diet in particular.
Be that as it may, short-term studies, especially those that are not randomized, tend to show a benefit. But what happens over time is when studies get longer, when they reach 6 months, the difference in benefit for diabetes tends to be reduced. By the time you arrive at 12 months, it is close to zero, then when you spend 12 months, it is zero.
For diabetes, the difference tends to disappear, with any potential benefit disappearing after a year or more. And if we know that diabetes is not transient, people tend to suffer for long periods of time. It is therefore important to have a lasting advantage.
Norman Swan: What about heart risk factors? Atkins used to say, well, it's intuitively … it's counterintuitive, but my Atkins diet is really good for your heart because of the shift to fat metabolism. What do we know about heart risk factors and cardiovascular health in the ketogenic diet?
Shivam Joshi: We do not have any difficult results, so we use surrogate results, which means that we look at cholesterol markers. Some markers improve and others deteriorate. What matters most is the controversial debate. So, LDL has been shown to make it worse …
Norman Swan: This is low density lipoprotein cholesterol, supposed to be the bad form of cholesterol that is deposited in your arteries.
Shivam Joshi: Exactly, and it's the one that preoccupies doctors from the beginning and even until today, and those that we … the marker we use. But with this movement that tends to overlap with the resistance to the status quo and duplicates what happens in politics, strangely enough, it is argued that maybe LDL is not as important anymore, and there may be other problems that matters. And I think that might be wishful thinking because the ketogenic diet has been shown to increase LDL. However, the increase in HDL does not necessarily correspond to the reduction of final parameters, such as heart attacks, deaths, strokes, and so on.
What is the best predictor of things is LDL, and even better than apolipoprotein B. When you start looking at studies, especially studies that are neutral in weight, if you lose weight in any way whatever it is, you will generally improve your cholesterol levels and your cardiovascular diseases. risk factors for most. It is therefore not surprising that LDL decreases with weight loss. It is therefore important to consider neutral weight studies. And in weight neutral studies, LDL increases and sometimes also apolipoprotein B, which is actually very worrisome, and sometimes the increase can reach 10, 20 points or more.
Norman SwanApart from that, does a ketogenic diet have any other serious side effects?
Shivam JoshiData continue to emerge in the adult literature, but the ketogenic diet is widely prescribed to the pediatric epilepsy population for nearly 100 years.
Norman Swan: Just to explain, it's about children with uncontrolled epilepsy, the drugs are not working very well and, for some reason, a ketogenic diet seems to help control their epilepsy.
Shivam Joshi: Exactly, and this patient population is different, they are children, they have underlying conditions that predispose them to epilepsy or refractory seizures. But he is insightful because there are side effects noted in this literature, some of which begin to show up in the adult literature is an increase in LDL and apolipoprotein B, two markers of substitution for cardiovascular disease. But there are also others that have been seen, such as vitamin and mineral deficiencies, constipation because traditional animal-based ketogenic diets, do not consume a lot of fiber, that fatigue , kidney stones are another important risk factor. As a physician trained in nephrology or the study of kidney disease, this interests me. There are a number of risk factors or side effects that have been noted in the literature on pediatric epilepsy that we expect to see if they are also present in the adult population.
Norman Swan: One of the arguments put forward by the people promoting the ketogenic diet is that it can not be so bad, if you look at the Inuit in Canada, they eat fat and fish and they do not eat carbohydrates so how can it be bad?
Shivam Joshi: Yes, the Inuit are an interesting population. They actually have a mutation to not be in ketosis, which is rather interesting because it makes you wonder why they would have such a mutation …
Norman Swan: I see, so they eat little carbohydrate, but it's not ketogenic.
Shivam JoshiWell, then do not put them in ketosis or as much ketosis as other populations. And some theorized online, in the depths of the Web, there could be an evolutionary adaptation, namely that having so much ketosis, which usually accompanies a mild form of d & # 39; Acidosis, can put people at risk if they develop, for example. , an infection, septic shock or famine …
Norman Swan: Oh, there was a selection process.
Shivam Joshi: Maybe, or something else, so we do not know, but it is certainly intriguing and interesting. The other thing is that the Inuit are not very healthy. Several studies have shown that their rates of cardiovascular disease are perhaps higher than those of Western populations, which is actually interesting. It may be hard to believe that someone might have a higher risk of developing heart disease than someone who already lives in the western population. But people have written about it. So this is worrying too.
The other thing that goes along with this diet is that people demonize what's called good carbs or your unrefined carbohydrates. With this movement, and I think that was really the goal of the newspaper, is that we said that the enthusiasm for the diet exceeded its evidence, but we also came to the defense of the apple or banana that , with the beginning of the ketogenic diet has since been demonized for its carbohydrate content. But these carbs are surrounded by fiber and are well packaged as a whole fruit. There are also vegetables that have recently been demonized because they are technically carbs, but not all carbohydrates are the same. So when people throw fruit and vegetables containing sugar, for example, they throw the baby with the bathwater.
Norman Swan: Because of the evidence that whole grains and so on are protective against colon cancer and heart disease. Shivam, have you ever tried a ketogenic diet?
Shivam Joshi: I have never tried the ketogenic diet, but there are many things that I have not tried …
Norman Swan: Let's not enter dangerous territory here.
Shivam Joshi: Yes, I have not tried smoking, for example, but I know that I do not need to try to smoke because I've read the newspapers about it, but that's one thing. But I'm not saying that the ketogenic diet is as dangerous as smoking because my critics will come after me, but, as I explain to others, I consider this as a drug made by a pharmaceutical company . if a pharmaceutical company came in and said, "We produce a drug that has a short-term benefit, but the profit goes down after a year, and it can be risky and has many alternatives," I do not know how many people would sign for it .
Norman Swan: Ok, well I hope the pitchforks are not going to land on you since Australia.
Shivam Joshi: I hear them from here!
Norman Swan: Shivam, thank you very much for joining us.
Shivam Joshi: No worries, anytime, thank you very much.
Norman Swan: Shivam Joshi is a doctor at the Faculty of Medicine at the University of New York at Bellevue.