Yesterday, as I was pondering what some Dietitians think with respect to what a ketogenic diet is and isn’t, it occurred to me that many people who follow me on social media and who follow a low carb or keto diet themselves, may not know the answers either. What started off as a single question, morphed into a series of 10 questions asked in Twitter polls which I will give the answers to here.
Please keep in mind, the questions were difficult to clearly formulate due to the limitation on the number of characters in Twitter polls.
While there is a common misconception that a ketogenic diet needs to have lots of butter, cream and bacon and/or lots of meat, eggs and cheese, most people got the right answer that for a weight loss diet to be classified as keto, it needs to have carbs < 50 g per day. A keto diet for weight loss is not about the amount of fat it has, but the amount of carbohydrate it has.
As covered in this article titled What Makes a Diet Low Carb or Keto is NOT How Much Fat it Contains, different people define “low carb” or “keto” level of carbohydrates in different ways, but Feinman et al  defined three categories of reduced-carbohydrate diets as follows;
(a) very low carbohydrate ketogenic: carbs limited to 20–50 g per day or < 10% of total energy intake.
Note: What makes a keto diet ketogenic is that that low carbohydrate intake puts people into a state of ketosis, which is a normal physiological state that people go into after an overnight fast. It is where the body burns stored fat for energy, releasing ketones which can be used by the brain and other tissues.
(b) low carbohydrate: carbs limited to < 130 g per day or < 26% of total energy intake.
(c) moderate carbohydrate: carbs limited to 130–225 g per day or 26–45% of total energy intake.
I found the response to this question very interesting. While only a small number of people believed that protein, fats and carbs are all “essential nutrients” defined as ones the body can’t make but that have to be taken in through the diet, almost as many people only believed that protein and omega 3 fats are essential nutrients, as believed that some amino acids and some fatty acids are essential.
As covered in the article Which Protein Foods are Best for Weight Loss on a Low Carb Diet according the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids, there are two essential fatty acids (linoleic acid, alpha-linolenic acid) and the nine essential amino acids(the building blocks of protein), including histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine that the body can’t manufacture. As covered in How Much Carbohydrate is Essential in the Diet, there is no essential carbohydrate.
The answers to this question seemed to capture an underlying belief that a ketogenic diet for weight loss must have a certain amount of fat to be “keto” relative to a therapeutic ketogenic diet for epilepsy or seizure disorder — with 1/3 of people saying a weight-loss keto diet needed to have either a 4:1, 3:1 or 2:1 ratio of fat to (protein plus carbs) or a 3:1 or 2:1 ratio. Another 8% believed a keto diet for weight loss needs to have twice as much fat as protein plus carbs. Less than 60% got the answer correct, that for a weight loss diet to be keto, it can be any ratio of protein or fat, given carbs are kept below 50g per day. As covered in How Much Carbohydrate is Essential in the Diet, page 275 of the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids states;
“The lower limit of dietary carbohydrate compatible with life apparently is zero, provided that adequate amounts of protein and fat are consumed. “
I guessed that very few people realize that the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids actually states that the amount of carbohydrate required in the diet is zero, provided that adequate amounts of protein and fat are consumed.
For those that have never seen it from the source, here it is page 275 of the Dietary Reference Intakes (DRIs) for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids;
On page 276 of the Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids (2005) it states:
“In the absence of dietary carbohydrate, de novo synthesis of glucose requires amino acids derived from the hydrolysis of endogenous or dietary protein or glycerol derived from fat. Therefore, the marginal amount of carbohydrate required in the diet in an energy-balanced state is conditional and dependent upon the remaining composition of the diet.”
That is, even when minimal amounts of carbohydrate is eaten, the body will synthesize the glucose needed by the brain from the protein taken in through the diet (provided it is in adequate amounts) or from glycerol which is formed when fat is broken down. If the protein in the diet (exogenous protein) is inadequate however, the body’s own protein (endogenous protein) will be used.
The answer to this question was also very interesting. Almost 1/2 (49%) of the 64 people that responded thought for a weight loss diet to be classified as keto, it needed to have either much more fat (22%) or more fat (27%) than protein. 13% thought for a weight loss diet to be keto it needed to have a bit more protein than fat and 40% got the answer correct, that it can have any mixture of protein or fat. Remember, what makes a weight loss diet ketogenic is how much carbohydrate it has, not how much fat or protein it has (see question #1, above).
Of concern, 1/4 of 85 people polled believed that there can never be serious side effects doing a keto diet. I would encourage everyone reading this post to read the article I wrote titled Don’t Try This at Home — the need for medication supervision which outlines the serious side effects that can occur if beginning a very low carb or ketogenic diet if taking
(2) medication to lower blood glucose such as sodium glucose co-transporter 2 (SGLT2) medication including Invokana, Forxiga, Xigduo, Jardiance, etc. and other types of glucose lowering medication such as Victoza, etc.
(3) medication for blood pressure such as Ramipril, Lasix (furosemide), Lisinopril / ACE inhibitors, Atenolol / β₁ receptor antagonists
(4) mental health medication such as antidepressants, medication for anxiety disorder, and mood stabilizers for bipolar disorder and schizophrenia.
Those who saw my talk at the Low Carb and Ketogenic Approach to Health summit last Sunday heard me refer to some discussion that had occurred on Twitter two weeks ago regarding the mistaken belief that ketosis is a pathological state.
Here is my response, with the reference.
Since I was limited in the number of characters I could put in the answers, technically both answers would be correct the way it is worded. Yes, ketoacidosis is a physiological state, but a pathological physiological state.
In type 1 diabetes or insulin dependent type 2 diabetes the beta cells don’t produce enough inusulin so glucose can’t be moved into the cells to be used as fuel (needs insulin). The body starts to break down fat stores (triglycerides) for energy at a very fast rate, resulting in a build up of ketones (also called keto acids). This excess keto acid buildup is called ketoacidosis and is a serious pathological condition that can be fatal.
Ketoacidosis can also occur if starting a very low carb or keto diet while taking certain medications (see question #7 for which medications).
The majority of the 108 people answering this question got the answer correct.
Almost all people with type 2 diabetes following a keto diet can experience remission of type 2 diabetes as long as they maintain a very low carbohydrate or ketogenic diet.
“Reversal” of a disease implies that whatever was causing it is now gone and is synonymous with using the term “cured”. In the case of someone with type 2 diabetes, reversal would mean that the person can now eat a standard diet and still maintain normal blood sugar levels. There are a few very limited cases in the literature of this occurring, but for the most part long term remission is usually what is attainable. This article titled The Difference Between Reversal and Remission of Type 2 Diabetes explains this in detail.
If you would like more information about how I can help you follow a low carb or keto diet, please send me a note using the Contact Me form on the tab above.
To your good health!
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- Feinman RD, Pogozelski WK, Astrup A, Bernstein RK, Fine EJ,Westman EC, et al. Dietary Carbohydrate Restriction as the First Approach in Diabetes Management: critical review and evidence base. Nutrition. 2015;31(1):1–13.
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