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  • Muscle Shrinkage and Bone Loss on Keto Diets?  | NutritionFacts.org

    Muscle Shrinkage and Bone Loss on Keto Diets?  | NutritionFacts.org

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    Ketogenic diets have been found to undermine exercise efforts and lead to muscle shrinkage and bone loss. 
     
    An official International Society of Sports Nutrition position paper covering keto diets notes the “ergolytic effect” of keto diets on both high- and low-intensity workouts. Ergolytic is the opposite of ergogenic. Ergogenic means performance-boosting, whereas ergolytic means performance-impairing. 
     
    For nonathletes, ketosis may also undermine exercise efforts. Ketosis was correlated with increased feelings of “perceived exercise effort” and “also significantly correlated to feelings of ‘fatigue’ and to ‘total mood disturbance,’” during physical activity. “Together, these data suggest that the ability and desire to maintain sustained exercise might be adversely impacted in individuals adhering to ketogenic diets for weight loss.” 
     
    You may recall that I’ve previously discussed that shrinkage of measured muscle mass among CrossFit trainees has been reported. So, a ketogenic diet may not just blunt the performance of endurance athletes, but their strength training as well. As I discuss in my video Keto Diets: Muscle Growth and Bone Density, study participants performed eight weeks of the battery of standard upper and lower body training protocols, like bench presses, pull-ups, squats, and deadlifts, and there was no surprise. You boost muscle mass—unless you’re on a keto diet, in which case there was no significant change in muscle mass after all that effort. Those randomized to a non-ketogenic diet added about three pounds of muscle mass, whereas the same amount of weight lifting on the keto diet tended to subtract muscle mass by about 3.5 ounces on average. How else could you do eight weeks of weight training and not gain a single ounce of muscle on a ketogenic diet? Even keto diet advocates call bodybuilding on a ketogenic diet an “oxymoron.” 
     
    What about bone loss? Sadly, bone fractures are one of the side effects that disproportionately plague children placed on ketogenic diets, along with slowed growth and kidney stones. Ketogenic diets may cause a steady rate of bone loss as measured in the spine, presumed to be because ketones are acidic, so keto diets can put people in what’s called a “chronic acidotic state.” 
     
    Some of the case reports of children on keto diets are truly heart-wrenching. One nine-year-old girl seemed to get it all, including osteoporosis, bone fractures, and kidney stones, then she got pancreatitis and died. Pancreatitis can be triggered by having too much fat in your blood. As you can see in the graph below and at 2:48 in my video, a single high-fat meal can cause a quintupling of the spike in triglycerides in your bloodstream within hours of consumption, which can put you at risk for inflammation of the pancreas.  

    The young girl had a rare genetic disorder called glucose transporter deficiency syndrome. She was born with a defect in ferrying blood sugar into her brain. That can result in daily seizures starting in infancy, but a ketogenic diet can be used as a way to sneak fuel into the brain, which makes a keto diet a godsend for the 1 in 90,000 families stricken with this disorder.

    As with anything in medicine, it’s all about risks versus benefits. As many as 30 percent of patients with epilepsy don’t respond to anti-seizure drugs. Unfortunately, the alternatives aren’t pretty and can include brain surgery that implants deep electrodes through the skull or even removes a lobe of your brain. This can obviously lead to serious side effects, but so can having seizures every day. If a ketogenic diet can help with seizures, the pros can far outweigh the cons. For those just choosing a diet to lose weight, though, the cost-benefit analysis would really seem to go the other way. Thankfully, you don’t need to mortgage your long-term health for short-term weight loss. We can get the best of both worlds by choosing a healthy diet, as I discussed in my video Flashback Friday: The Weight Loss Program That Got Better with Time.
     
    Remember the study that showed the weight loss was nearly identical in those who had been told to eat the low-carb Atkins diet for a year and those told to eat the low-fat Ornish diet, as seen below and at 4:18 in my video? The authors concluded, “This supports the practice of recommending any diet that a patient will adhere to in order to lose weight.” That seems like terrible advice. 

    There are regimens out there like “The Last Chance Diet which consisted of a low-calorie liquid formula made from leftover byproducts from a slaughterhouse [that] was linked to approximately 60 deaths from cardiovascular-related events.” An ensuing failed lawsuit from one widower laid the precedent for the First Amendment protection for those who produce deadly diet books. 

    It’s possible to construct a healthy low-carb diet or an unhealthy low-fat one—a diet of cotton candy would be zero fat—but the health effects of a typical low-carb ketogenic diet like Atkins are vastly different from a low-fat plant-based diet like Ornish’s. As you can see in the graph below and at 5:26 in my video, they would have diametrically opposed effects on cardiovascular risk factors in theory, based on the fiber, saturated fat, and cholesterol contents of their representative meal plans. 

    And when actually put to the test, low-carb diets were found to impair artery function. Over time, blood flow to the heart muscle itself is improved on an Ornish-style diet and diminished on a low-carb one, as shown below and at 5:44 in my video. Heart disease tends to progress on typical weight-loss diets and actively worsens on low-carb diets, but it may be reversed by an Ornish-style diet. Given that heart disease is the number one killer of men and women, “recommending any diet that a patient will adhere to in order to lose weight” seems irresponsible. Why not tell people to smoke? Cigarettes can cause weight loss, too, as can tuberculosis and a meth habit. The goal of weight loss is not to lighten the load for your pallbearers. 

     
    For more on keto diets, see my videos on the topic. Interested in enhancing athletic performance? Check out the related videos below. 

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    Michael Greger M.D. FACLM

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  • The Safety of Keto Diets  | NutritionFacts.org

    The Safety of Keto Diets  | NutritionFacts.org

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    What are the effects of ketogenic diets on nutrient sufficiency, gut flora, and heart disease risk? 

    Given the decades of experience using ketogenic diets to treat certain cases of pediatric epilepsy, a body of safety data has accumulated. Nutrient deficiencies would seem to be the obvious issue. Inadequate intake of 17 micronutrients, vitamins, and minerals has been documented in those on strict ketogenic diets, as you can see in the graph below and at 0:14 in my video Are Keto Diets Safe?. 

    Dieting is a particularly important time to make sure you’re meeting all of your essential nutrient requirements, since you may be taking in less food. Ketogenic diets tend to be so nutritionally vacuous that one assessment estimated that you’d have to eat more than 37,000 calories a day to get a sufficient daily intake of all essential vitamins and minerals, as you can see in the graph below and at 0:39 in my video. 


    That is one of the advantages of more plant-based approaches. As the editor-in-chief of the Journal of the American Dietetic Association put it, “What could be more nutrient-dense than a vegetarian diet?” Choosing a healthy diet may be easier than eating more than 37,000 daily calories, which is like putting 50 sticks of butter in your morning coffee. 
     
    We aren’t just talking about not reaching your daily allowances either. Children have gotten scurvy on ketogenic diets, and some have even died from selenium deficiency, which can cause sudden cardiac death. The vitamin and mineral deficiencies can be solved with supplements, but what about the paucity of prebiotics, the dozens of types of fiber, and resistant starches found concentrated in whole grains and beans that you’d miss out on? 
     
    Not surprisingly, constipation is very common on keto diets. As I’ve reviewed before, starving our microbial self of prebiotics can have a whole array of negative consequences. Ketogenic diets have been shown to “reduce the species richness and diversity of intestinal microbiota,” our gut flora. Microbiome changes can be detected within 24 hours of switching to a high-fat, low-fiber diet. A lack of fiber starves our good gut bacteria. We used to think that dietary fat itself was nearly all absorbed in the small intestine, but based on studies using radioactive tracers, we now know that about 7 percent of the saturated fat in a fat-rich meal can make it down to the colon. This may result in “detrimental changes” in our gut microbiome, as well as weight gain, increased leaky gut, and pro-inflammatory changes. For example, there may be a drop in beneficial Bifidobacteria and a decrease in overall short-chain fatty acid production, both of which would be expected to increase the risk of gastrointestinal disorders. 
     
    Striking at the heart of the matter, what might all of that saturated fat be doing to our heart? If you look at low-carbohydrate diets and all-cause mortality, those who eat lower-carb diets suffer “a significantly higher risk of all-cause mortality,” meaning they live, on average, significantly shorter lives. However, from a heart-disease perspective, it matters if it’s animal fat or plant fat. Based on the famous Harvard cohorts, eating more of an animal-based, low-carb diet was associated with higher death rates from cardiovascular disease and a 50 percent higher risk of dying from a heart attack or stroke, but no such association was found for lower-carb diets based on plant sources.  
     
    And it wasn’t just Harvard. Other researchers have also found that “low-carbohydrate dietary patterns favoring animal-derived protein and fat sources, from sources such as lamb, beef, pork, and chicken, were associated with higher mortality, whereas those that favored plant-derived protein and fat intake, from sources such as vegetables, nuts, peanut butter, and whole-grain bread, were associated with lower mortality…” 
     
    Cholesterol production in the body is directly correlated to body weight, as you can see in the graph below and at 3:50 in my video. 

    Every pound of weight loss by nearly any means is associated with about a one-point drop in cholesterol levels in the blood. But if we put people on very-low-carb ketogenic diets, the beneficial effect on LDL bad cholesterol is blunted or even completely neutralized. Counterbalancing changes in LDL or HDL (what we used to think of as good cholesterol) are not considered sufficient to offset this risk. You don’t have to wait until cholesterol builds up in your arteries to have adverse effects either; within three hours of eating a meal high in saturated fat, you can see a significant impairment of artery function. Even with a dozen pounds of weight loss, artery function worsens on a ketogenic diet instead of getting better, which appears to be the case with low-carb diets in general.  

    For more on keto diets, check out my video series here. 

    And, to learn more about your microbiome, see the related videos below.

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    Michael Greger M.D. FACLM

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  • Diabetes Associations Recognize Plant-Based Diets  | NutritionFacts.org

    Diabetes Associations Recognize Plant-Based Diets  | NutritionFacts.org

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    Plant-based diets are the single most important—yet underutilized—opportunity to reverse the pending obesity and diabetes-induced epidemic of disease and death. 

    Dr. Kim Williams, immediate past president of the American College of Cardiology, started out an editorial on plant-based diets with the classic Schopenhauer quote: “All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.” In 2013, plant-based diets for diabetes were in the “ridiculed” stage in the official endocrinology practice guidelines and placed in the “Fad Diets” section. The guidelines acknowledged that strictly plant-based diets “have been shown to reduce the risk for T2DM [type 2 diabetes] and improve management of T2DM” better than the American Diabetes Association recommendations, then inexplicably went on to say that it “does not support the use of one type of diet over another” with respect to diabetes or in general. “The best approach for a healthy lifestyle is simply the ‘amelioration of unhealthy choices’”—whatever that means. 

    But, by 2015, the clinical practice guidelines from the same professional associations explicitly endorsed a plant-based diet as its general recommendation for diabetic patients. The times they are a-changin’! 

    As I discuss in my video Plant-Based Diets Recognized by Diabetes Associations, the American Diabetes Association itself is also now on board, listing plant-based eating as one of the dietary patterns acceptable for the management of the condition. The Canadian Diabetes Association, however, has really taken the lead. “Type 2 diabetes mellitus is considered one of the fastest growing diseases in Canada, representing a serious public health concern,” so it isn’t messing around and recommends plant-based diets for disease management “because of their potential to improve body weight and A1C [blood sugar control], LDL-cholesterol, total cholesterol and non-HDL-cholesterol levels, in addition to reducing the need for diabetes medications.” The Canadian Diabetes Association uses the Kaiser Permanente definition for that eating pattern: “a regimen that encourages whole, plant-based foods and discourages meats, dairy products and eggs, as well as all refined and processed foods,” that is, junk. 

    It recommends that diabetes education centers in Canada “improve patients’ perceptions of PBDs [plant-based diets] by developing PBD-focused educational and support as well as providing individualized counseling sessions addressing barriers to change.” The biggest obstacle identified to eating plant-based was ignorance. Nearly nine out of ten patients interviewed “had not heard of using a plant-based diet to treat or manage T2DM.” Why is that? “Patient awareness of (and interest in) the benefits of a plant-based diet for the management of diabetes…may be “influenced by the perception of diabetes educators and clinicians.” Indeed, most of the staff were aware of the benefits of plant-based eating for treating diabetes, yet only about one in three were recommending it to their patients.  

    Why? One of the common reasons given was they didn’t think their patients would eat plant-based, so they didn’t even bring it up, but “[t]his notion is contrary to the patient survey results that almost two-thirds of patients were willing” to at least give it a try. The researchers cite the PCRM Geico studies I’ve covered in other videos, in which strictly plant-based diets were “well accepted with over 95% adherence rate,” presumably because the study participants just felt so much better, reporting “increased energy level, better digestion, better sleep, and increased satisfaction when compared with the control group.” 

    A number of staff members also expressed they were unclear about the supportive scientific evidence as their second reason for not recommending this diet, but it’s been shown to be more effective than an American Diabetes Association–recommended diet at reducing the use of diabetes medications, long-term blood sugar control, and cholesterol. It’s therefore possible that the diabetes educators were simply behind the times, as there is “a lag-time” in the dissemination of new scientific findings from the literature to the clinician and finally to the patient. Speeding up this process is one of the reasons I started NutritionFacts.org. 

    As Dr. Williams put it, “the ‘truth’ (i.e., evidence) for the benefits of plant-based nutrition continues to mount. This now includes lower rates of stroke, hypertension, diabetes mellitus, obesity, myocardial infarction, and mortality [heart attacks and cardiac death], as well as many non-cardiac issues that affect our patients in cardiology, ranging from cancer to a variety of inflammatory conditions.” We’ve got the science. The bigger challenge is overcoming the “inertia, culture, habit, and widespread marketing of unhealthy foods.” He concludes, “Reading the existing literature and evaluating the impact of plant-based nutrition, it clearly represents the single most important yet underutilized opportunity to reverse the pending obesity and diabetes-induced epidemic of morbidity and mortality,” disease and death. 

    I highlighted the PCRM Geico studies in my videos Slimming the Gecko and Plant-Based Workplace Intervention. 

    Aren’t plant-based diets high in carbs? Get the “skinny” by checking out my video Flashback Friday: Benefits of a Macrobiotic Diet for Diabetes. 

    To learn more about diet’s effect on type 2 diabetes, see the related videos below. 

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    Michael Greger M.D. FACLM

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