When does a ketogenic diet become a drug?

The popularity of the keto diet continues to grow . How is it different from other diets and what is it about putting the body into a state of ketosis that is its goal?

Katarzyna Drąg: The ketogenic diet, also known as the ketogenic diet or colloquially keto diet, is a diet characterized by low carbohydrate (about 5-10% of energy) and high fat intake (about 70-90% of energy). In comparison, a standard diet provides 45-65% of energy from carbohydrates and 20-35% from fats. The proportion of protein in both cases is similar and should be within the recommended standard for the age.

Such a modification of the composition of the diet means that the amount of glucose (i.e. the main source of energy for cells) that the body obtains from food is insufficient to meet its energy needs, and in order to continue to function it is forced to produce energy from other compounds alternative to glucose. These are ketone bodies (a.k.a. ketones), produced in the liver, through the metabolism of fats. After a few days or weeks of such feeding, cells begin to treat ketones as the primary energy substrate, and the body enters a state of ketosis.

You can find out whether a person is in a state of ketosis by measuring the concentration of beta-hydroxybutyrate in the blood, a ketone body that makes up about 80% of all ketones. It is assumed that optimal values should be in the range of 0.5-3 mmol/L. Higher results are obtained primarily for therapeutic purposes. In people who are not on a diet, ketones in the blood are virtually non-existent (<0.22 mmol/l).

The ketogenic diet is not an entirely new, revolutionary idea for burning fat. It originated in the early 20th century as a way to treat epilepsy. Is this moment considered the beginning of its use as a therapeutic diet?

The first half of the 20th century is believed to have been groundbreaking in terms of the emergence of the ketogenic diet. It was then that the results of the first clinical trials were published, documenting its positive effects in the treatment of epilepsy. This does not mean, however, that ketosis had not been used to treat it before. It was, and had been in ancient times. Scientists, unaware of the mechanisms responsible for the control of epileptic seizures, recommended periodic fasts to patients, and noticing an improvement afterwards, in the absence of other therapeutic methods, continued to use them for many more centuries. Information on this subject can be found, among others, in the works of Hippocrates, BC. Starvation, like the ketogenic diet, leads to the production of ketones from accumulated adipose tissue, but in practice it is not possible to maintain for a long time, as it can lead to death. Thus, the ketogenic diet began to be regarded as its better alternative, since it could be used for a long time. Over the years, its positive effects also began to be used in the treatment of other diseases, although it is now mainly associated as one of the weight-loss diets.

The creators of the diet recognized that burning fat requires eating fat. In light of current recommendations, it is recognized that vegetables and fruits should predominate in a healthy diet. In this context, is the keto diet definitely good for health?

According to the recommendations for healthy eating published by the National Center for Nutrition Education (NCEŻ), it is assumed that the content of vegetables and fruits in the diet should be at least 400 g per day, with vegetables predominating. They are rich in vitamins and minerals, soluble fiber fractions, and (especially vegetables) low in calories. The ketogenic diet does not exclude these foods from the menu, and their amount will depend on several factors. First, on the set daily value of carbohydrates at which a person will remain in ketosis. This is an individual issue. A sizable group of people will be able to eat about 40-50 g of carbohydrates per day, and with this amount we are able to fit the value required by the NCEZ. Secondly, it depends on what vegetables and fruits we eat. It is recommended that a healthy diet should include primarily non-starchy vegetables and berries, which contain fewer carbohydrates than, for example, starchy vegetables or sweet fruits such as banana, grapes and mango. Equally important is what other sources of carbohydrates we include in the daily menu. We can supplement dietary fiber by including eggplant or psyllium in the diet, for example.

Following the current recommendations when it comes to these food groups, although not always, is possible on a ketogenic diet. It is worth striving for the best possible composition of the menu. With good effects of the diet, any deficiencies can always be compensated for with properly selected supplementation.

Can this diet be followed on its own? And is it good for healthy but overweight people who just want to lose weight?

Proper management of the ketogenic diet requires specialized knowledge, so you should not follow it on your own. If improperly composed, it can even worsen your health. During its course, various side effects may occur, requiring prompt medical intervention. Before starting the diet, a number of necessary tests should be performed to exclude contraindications to its use. It is also necessary to constantly monitor it.

This should also be borne in mind by people who, without specific medical indications, only want to lose weight through a ketogenic diet. Whether a diet sheds weight depends on its negative energy balance. A ketogenic diet does not necessarily have to meet this condition, although the exclusion of traditional sweets, salty snacks, fast food or sugary drinks often provides this caloric deficit. It also exhibits several actions conducive to weight loss, such as affecting the hormones that control appetite, so it can lower cravings, and maintaining stable glycemic levels and accompanying fewer hunger attacks. Unfortunately, the restrictive nature of the diet means that without a strong motivation to follow it, it will be difficult to persevere on it for a long time, and returning to previous eating habits will give us a yo-yo effect and make up for the lost pounds. The right diet should be determined individually. Especially since no research confirms that there is any one diet more effective in reducing weight than others .

When does the keto diet become a drug or therapy to support treatment? ( Alzheimer's disease, Parkinson's disease, autism, amyotrophic lateral sclerosis, brain tumors, headaches and sleep disorders, epilepsy). What is its proven effectiveness? What metabolic changes does it cause in the body that allow it to improve health?

The ketogenic diet is definitely increasingly being used by specialists as a method of treatment or a therapy to support this treatment, not only for epilepsy, but also for a number of other diseases or disorders. This is due to its multidirectional mechanisms of action. This diet reduces inflammatory processes and oxidative stress. It can also lead to an improved lipid profile, by lowering triglycerides, as well as raising HDL cholesterol. In people with diabetes, it normalizes glycemia, lowers glycated hemoglobin levels and improves insulin sensitivity. In neurological diseases, where glucose absorption, transport and metabolism are often impaired, ketone bodies improve mitochondrial function and have a neuroprotective effect, preventing neuronal degeneration and death. In people with Alzheimer's disease, improvements in cognitive function are noted after dietary intake, which may be related to reduced beta-amyloid deposition in the brain. The results of the cancer studies are also promising. They suggest that the ketogenic diet can inhibit the development of certain types of cancer, improve the sensitivity of cancer cells to chemotherapy and radiation therapy, and prevent the loss of muscle tissue during treatment. Its positive effects are also noted in polycystic ovary syndrome, cardiovascular disease and improved sleep quality, among others. It is also the treatment of choice for two inborn defects of metabolism - glucose transporter type 1 deficiency and pyruvate dehydrogenase deficiency.

How often is the keto diet implemented in the treatment of children with drug-resistant epilepsy. What is its effectiveness based on?

In Poland, the number of children with drug-resistant epilepsy being introduced to the ketogenic diet is steadily increasing. This is due to the fact that more and more hospitals are beginning to offer this form of treatment to their patients. Currently, there are approx. 17 such centers. This may not be an impressive result, given the more than 100-year history of this diet related to epilepsy, but the more specialists are exposed to it in their professional practice, the more they will be converted to it. Demand from patients is high. However, there is a shortage of properly trained dietitians and doctors willing to take on the task. In theory, the inclusion of a ketogenic diet should be considered in those patients who, despite the use of at least two well-chosen and dosed medications, do not see improvement. In practice, it is often treated as a last resort when all other treatments have been exhausted.

In terms of the therapeutic properties of the ketogenic diet, epilepsy is the best studied disease. There have been many scientific studies documenting its effects on eliminating or reducing seizures and improving overall health. The mechanisms responsible for this are complex in nature and have still not been completely elucidated. The diet has anticonvulsant and neuroprotective effects. These positive effects are mainly due to ketone bodies and polyunsaturated fatty acids, which are supplied with food in larger quantities than average. Among other things, they are believed to improve neuronal function, raise the seizure threshold and stabilize the function of synapses. They also exhibit anti-inflammatory and antioxidant effects. Moreover, they affect the receptors that regulate the synthesis of gamma-aminobutyric acid (GABA), an amino acid that inhibits neuronal excitability.

Is the ketogenic diet for epilepsy only used to treat children or adults as well?

It can be successfully used in both children and adults. In Poland, however, there are virtually no centers where adults with epilepsy can be treated with the ketogenic diet. This is due to the difficulty of obtaining a complete staff, consisting of a neurologist and a dietician, within a single medical facility, who could deal with it. This situation is particularly problematic for patients who are over the age of 18 while on the diet. They have great difficulty finding a place where they can continue their treatment.

And what are the sources of essential carbohydrates? Glucose in the keto diet ceases to be a source of energy. Where then can it be obtained from?

Glucose ceases to be the main source of energy which does not mean that the body does not use it at all. Some cells are unable to use ketones and can only function properly because of it. This applies, for example, to erythrocytes. Brain tissue, despite the state of ketosis, will also meet a certain percentage of its energy needs with glucose. The very fact that the body, by way of gluconeogenesis, is able to produce it for itself from lactate, glucogenic amino acids and glycerol is proof of how important it is. In people on a ketogenic diet, blood glucose levels are naturally slightly lower than with a standard diet and fluctuate between 60-100 mg/dl.

Carbohydrates can be found in many products, even in those where you wouldn't expect them. On a ketogenic diet, their main sources are non-starchy vegetables (including greens, sprouts, peppers, tomato), mushrooms, berries, avocados, some pulses (broad beans, green peas), nuts, seeds, dark chocolate, fatty dairy products or flours (almond, coconut). Many drugs, dietary supplements, toothpastes or flavored lip glosses also contain them, and these products should be watched out for.

I understand that the decision on issues of treatment with the ketogenic diet can only be made by a doctor and clinical nutritionist?

Treatment with the ketogenic diet should always be under the supervision of a doctor and nutritionist specialized in its management. Merely graduating from medical school does not confer such authority, as it is such a complex and extensive subject that it requires undergoing appropriate training and continuous updating of knowledge.

What should be paid special attention to in order not to squander the results achieved, not to spoil the effects? Especially when it comes to treating children with drug-resistant epilepsy?

Children with drug-resistant epilepsy treated with a ketogenic diet always have their diet parameters individually set, including the amount of carbohydrates they can consume per day. They are often very sensitive to even small amounts of them in excess, which manifests itself in the occurrence of epileptic seizures even after a few or several minutes of additional consumption. This situation often occurs in EDs and hospital wards, where medical personnel connect patients to glucose drips or administer drugs containing carbohydrates. Sometimes, of course, this is necessary and the priority is to save lives, but whenever possible, medicines that do not contain them should be used. Parents are obliged to inform the staff of the facility in question that their child is on a ketogenic diet and should provide them with such a list of allowed medications. Also, those in the child's immediate environment should not give the child any products to eat without the permission of the caregivers.

What are the contraindications to the ketogenic diet and possible side effects?

Contraindications to the ketogenic diet include liver or kidney failure, severe kidney stones, pancreatitis, biliary stones, osteoporosis, severe gastroesophageal reflux, hypoglycemia of unexplained cause, some heart disease or inborn metabolic defects associated with fat metabolism. At the same time, it is worth noting that these are subject to change as a result of emerging new research.

We can divide the side effects depending on the length of the diet into early and late effects. Early, they appear mainly during the period of adaptation to ketosis and are mainly related to the impaired functioning of the digestive system and the not yet efficient extraction of energy from ketones. They are commonly referred to as keto flu. They include nausea, vomiting, abdominal pain, loss of appetite, fatigue, concentration problems or hypoglycemia. They usually last from a few to several days. In contrast, late side effects include: constipation, carnitine deficiency, kidney stones, osteopenia or growth disorders in children. With a well-planned and managed diet, however, many of these can be avoided.

While on a ketogenic diet, should I have regular checkups?

Regular checkups during the course of the diet are very important, as they allow the positive and negative effects of the diet to be monitored on an ongoing basis. Most often, they include blood and urine tests, weight and height measurements in children, and a general health assessment. The decision on their scope and frequency is made by the doctor. If the results are abnormal, dietary parameters can be modified on an ongoing basis and, if nutritional deficiencies are found, appropriate supplementation can be included. Based on them, the doctor can also make changes in the dosage or number of medications taken so that the treatment is as effective as possible.

Monitoring diet is particularly important in children. Due to their continuous development, as well as growth, they have increased nutritional needs and are thus at greater risk of developing nutritional deficiencies and being underweight. A restrictive, poorly managed ketogenic diet can be very dangerous for them and lead to stunted physical and intellectual development or cognitive decline.

Interviewed by Barbara Mietkowska