“Keto” is a word that generates some polarized responses throughout health and dieting communities. While some swear by it, others roll their eyes whenever the word is uttered. While it’s certainly a deviation from the norm, why the disdain? For it to have stuck around so long, there must be some merit, right?
Luckily, we at The MAPS Institute are here to separate fact from fiction and expose keto as either a trend bound for abandonment or a legitimate diet around to stay. Perhaps we’ll find it carving out a niche as it succeeds in limited situations, and fails in others. As a current follower, I will remove my biases here — I need to know the truth, too!
What Exactly Is Keto?
A keto diet requires low net carbs (20-50 grams a day, defined as carbs minus fiber), moderate protein, and high fats. The suggested ratio to maintain ketosis is to approach caloric intake as 4:1 — four parts fat, one part carbs and protein combined. An individual must maintain a 2:1 ratio when it is based on conditional adjustments.
The diet’s goal is to force the body into a state of “ketosis,” where the body completely changes what it relies on for energy. Normally, out of the three macronutrients (proteins, carbohydrates, and fats), the body relies on carbohydrates and fat for fuel and uses protein to replace dying cells throughout the body. Our digestive system turns carbohydrates into glucose (a form of sugar), our main energy source. When in ketosis, your body instead turns to fats to keep you going. To accommodate the different sources of caloric intake, the body breaks down fat into ketone bodies, or ketones for short. Ketones use a person’s diet or fat stores around the body to develop. You can achieve ketosis by following the diet or fasting.
Honorable Side Note
Speaking of fasting — that’s actually where the idea behind the ketogenic diet originates. Dr. Wilder in 1921 is the creator of the diet, but more on that later! The earliest recorded example of recommending fasting as a therapeutic treatment goes all the way back to the father of medicine himself: Hippocrates. He recommended fasting for children with uncontrollable seizures. After his time, there have been many other examples of fasting used to treat numerous conditions throughout history. Many religions have their devotees also undergo periods of fasting, often ascribing beneficial results — both spiritual and medical — to the practice. You can learn more about intermittent fasting with an article written by one of our very own experts, Erica Zellner, CNS, LDN, to gain valuable information on the benefits, history, and applicability for you!
How Does Ketosis Affect Our Bodies?
Since carbohydrates are the main sustenance our bodies rely on, deprivation of the macronutrient sets two metabolic processes in motion: gluconeogenesis, followed by ketogenesis. Gluconeogenesis begins when carbohydrate intake is drastically reduced. The liver produces glucose from lactic acid, glycerol, and the amino acids alanine and glutamine. Once glucose availability becomes scarce, insulin levels drop, causing the body to stop storing fat and glucose. This prompts the beginning of ketogenesis.
Once ketogenesis begins, we break down fat into fatty acids which are then metabolized into acetoacetate, the first of three ketone bodies. The molecule breaks down further into beta-hydroxybutyrate and acetone, the remaining two ketone bodies. Astonishingly, the body responds pretty well to this change. For the most part, short-term to medium-term ketosis is a safe state of being. Ketones are utilized easily by the body, passing through the blood-brain barrier to provide our brains with a plentiful source of energy.
Proven Medical Applications
I mentioned fasting earlier as a possible treatment for epilepsy earlier, and since keto mimics the effects, it can be used as a treatment. Common causes of epilepsy are metabolic disorders, so we can see why there might be results. The keto diet has a storied history, but in short, we can thank Dr. Wilder of the Mayo Clinic. In 1921, he concluded that the benefits of fasting could be achieved and extended by using a ketogenic diet. He even coined the term!
The keto diet was widely used throughout the 1920s and 1930s to treat childhood epilepsy. After the development of antiepileptic drugs, the use of the diet declined steadily over the decades. Then, a Dateline episode documented the successful application that stopped seizures in a 2-year old boy named Charlie. Since then, studies into the treatment have increased rapidly. The treatment is offered in nations throughout the world, though often as a last or next-to-last resort.
With medication becoming the main treatment for epilepsy, weight loss is the more common reason for adoption of the diet today. The keto diet is based around burning fat for fuel, so it makes sense that it could in some cases contribute to weight loss.
Possibilities and Complications
A plethora of studies on the ketogenic diet have been published thanks to renewed interest from the Dateline episode. Unfortunately, the short time since then has not allowed for much long-term research into a full list of eligible applications. There are, however, some exciting endeavors undertaken by scientists the world over. The notable prospects include cancer, diabetes, some neurological disorders, and certain cardiovascular issues. The possibilities are grande, but time and effort are required before any definitive statements can be made.
Regrettably, I’m afraid they all require far more research. This article provides some basic insight into possible applications for keto as treatment. The big one would have to be cancer. While keto would not manage as a stand-alone therapy for the condition, it can potentially serve as a supplemental addition. The reasoning here rests on the idea of malignant cancer cells utilizing sugars as fuel and insulin as a growth hormone to facilitate spreading. The deprivation of carbohydrates and glucose could create a problem for cancer cells. It is hypothesized that they cannot readily swap to using ketones like normal cells can. A ketogenic diet has also been found to decrease pro-inflammatory TH17 cells in the guts, likely meaning it could reduce inflammation overall.
Presence of Risks
One of the primary concerns for doctors is ketoacidosis. This is when the body overloads with ketones, and insulin production becomes extremely limited. Though the likelihood of developing ketoacidosis is negligible in non-diabetic individuals, it remains a problem for diabetics.
Again, we continue to suffer from a lack of research. Many doctors contend that there can be a potential increase in risk for cardiovascular issues. Vitamin deficiencies and lack of fiber are also concerns. This article goes into some detail about potential risks, and this article goes in-depth about benefits and risks alike. Ultimately, just about every source I found concluded that no definitive statements can be made.
Sustainability and Reliability
Since the resurgence of the ketogenic diet, long-term studies on benefits and risks are few and far between. Most studies’ results can’t be generalized to the public since they utilized small sample sizes. Another issue is the relatively high dropout rate of dieters. The two major contributing factors are restrictiveness and potential expense. Reliance on animal fats and avoidance of cost-efficient foods like rice, fruit, and certain vegetables contribute to concerns about cost.
As far as reliability is concerned, it all comes down to research. The lack of robust, large studies that last for extended periods of time contributes to the distrust of the diet as a treatment for many conditions. Scientists only agree that it works for epilepsy and obesity. But studies on any other condition are regarded as unreliable. Many participants drop out before significant time passes, and small sample sizes don’t help. At the end of the day, we need more information and more time to get a true grasp of efficacy and reliability.
Where Does This Leave Us?
So what’s the conclusion here?
I think the journey must continue. Metabolic changes affect our biochemistry in complicated ways. There needs to be much more research into the keto diet.
Weight loss is a proven benefit. The diet is safe to follow for at least six to 12 months. I’m three months into my own keto foray, and I’m hoping to keep it up for that full year. I’ll warn you, however, that starting and maintaining the diet is difficult. Cheat days set you back because they kick you out of ketosis. It can take several days for you to get back into that metabolic state. The change in foods can be rather hard, too. I miss potatoes very dearly! Luckily, there are many alternatives nowadays, and the market is currently exploding with new products.
Speak to a nutritionist first — or at least your general practitioner — to see if it’s right for you.
Fad or Fab?
The keto diet is here to stay for the foreseeable future. Its sharp rise in popularity has generated a lot of interest, and the medical community genuinely wants to learn more about it. Studies may not be abundant at the time of writing this, but many are still underway. It looks like interest in the keto diet’s applications, benefits, and risks aren’t going away anytime soon.
I wouldn’t say the keto diet’s a fad. Unfortunately, we can’t call it fab either without more investigation. For now, we can comfortably call it “pretty alright.”
Image credit: Total Shape
“Acetoacetate: What Is It, Why It’s Important & The Benefits,” Ruled Me (blog), June 13, 2018, https://www.ruled.me/what-is-acetoacetate/.
PubChem, “Acetone”, https://pubchem.ncbi.nlm.nih.gov/compound/180.
CDC, “Adult Obesity,” Centers for Disease Control and Prevention, March 22, 2021, https://www.cdc.gov/obesity/adult/causes.html.
Jennifer T Batch et al., “Advantages and Disadvantages of the Ketogenic Diet: A Review Article,” Cureus 12, no. 8: e9639, https://doi.org/10.7759/cureus.9639.
“Amino Acids: MedlinePlus Medical Encyclopedia,” https://medlineplus.gov/ency/article/002222.htm.
“BETA-HYDROXYBUTYRATE (BHB): Overview, Uses, Side Effects, Precautions, Interactions, Dosing and Reviews,” https://www.webmd.com/vitamins/ai/ingredientmono-1569/beta-hydroxybutyrate-bhb.
A Paoli et al., “Beyond Weight Loss: A Review of the Therapeutic Uses of Very-Low-Carbohydrate (Ketogenic) Diets,” European Journal of Clinical Nutrition 67, no. 8 (August 2013): 789–96, https://doi.org/10.1038/ejcn.2013.116.
“Blood Sugar,” Text (National Library of Medicine), https://medlineplus.gov/bloodsugar.html.
“Calculate Your BMI – Standard BMI Calculator,” https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
“Controlling the Global Obesity Epidemic,” https://www.who.int/activities/controlling-the-global-obesity-epidemic.
“Dateline NBC – Video Dailymotion,” Dailymotion, April 25, 2008, https://www.dailymotion.com/video/x576ng.
“Diabetic Ketoacidosis – Symptoms and Causes,” https://www.mayoclinic.org/diseases-conditions/diabetic-ketoacidosis/symptoms-causes/syc-20371551.
“Fasting | Definition, Description, Types, Benefits, & Facts | Britannica,” https://www.britannica.com/topic/fasting.
“Fasting Around the World,” Cultural Awareness (blog), January 22, 2015, https://culturalawareness.com/fasting-around-the-world/.
“Fasting Has Been a Cultural Norm For Decades and Is Now a Hot Topic – But Is It Healthy? – The MAPS Institute,” https://themapsinstitute.com/should-you-try-intermittent-fasting/.
“Gluconeogenesis – an Overview | ScienceDirect Topics,” accessed April 7, 2022, https://www.sciencedirect.com/topics/medicine-and-dentistry/gluconeogenesis.
James W. Wheless, “History of the Ketogenic Diet,” Epilepsia 49, no. s8 (2008): 3–5, https://doi.org/10.1111/j.1528-1167.2008.01821.x.
“History and Origin of the Ketogenic Diet | SpringerLink,” https://link.springer.com/chapter/10.1007/978-1-59259-808-3_2.
“Intermittent Fasting: What Is It, and How Does It Work?,” https://www.hopkinsmedicine.org/health/wellness-and-prevention/intermittent-fasting-what-is-it-and-how-does-it-work.
“Keto Diet: Benefits and Nutrients,” January 7, 2020, https://www.medicalnewstoday.com/articles/319196.
Alex Reed, “Keto Diet Statistics in 2022 (U.S. Data),” Bodyketosis (blog), February 23, 2022, https://bodyketosis.com/keto-diet-statistics/.
“Ketogenesis: Steps, Pathway, Significance,” https://byjus.com/neet/ketogenesis/.
Wajeed Masood, Pavan Annamaraju, and Kalyan R. Uppaluri, “Ketogenic Diet,” in StatPearls (Treasure Island (FL): StatPearls Publishing, 2022), http://www.ncbi.nlm.nih.gov/books/NBK499830/.
“Ketogenic Diet Benefits for Medical Conditions,” https://www.diabetes.co.uk/keto/keto-diet-and-other-conditions.html.
Antonio Paoli, “Ketogenic Diet for Obesity: Friend or Foe?,” International Journal of Environmental Research and Public Health 11, no. 2 (February 2014): 2092–2107, https://doi.org/10.3390/ijerph110202092.
“Medical Definition of Ketone Bodies,” https://www.rxlist.com/ketone_bodies/definition.htm.
“METABOLIC ETIOLOGY,” https://www.epilepsydiagnosis.org/aetiology/metabolic-groupoverview.html.
“Obesity,” Text (National Library of Medicine), https://medlineplus.gov/obesity.html.
“Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association | Circulation,” https://www.ahajournals.org/doi/10.1161/CIR.0000000000000973.
“The Keto Diet and Long-Term Weight Loss: Is It a Safe Option? – Inquiries Journal,” http://www.inquiriesjournal.com/articles/1807/the-keto-diet-and-long-term-weight-loss-is-it-a-safe-option.
“What Are Macronutrients? | MD Anderson Cancer Center,” https://www.mdanderson.org/publications/focused-on-health/what-are-macronutrients-.h15-1593780.html.
“What Is Epilepsy? Disease or Disorder?,” Epilepsy Foundation, https://www.epilepsy.com/learn/about-epilepsy-basics/what-epilepsy.
“What Is Ketosis? Learn About the Benefits and How to Achieve Ketosis,” Charlie Foundation (blog), https://charliefoundation.org/learn-about-ketosis/.
“What Is the Blood-Brain Barrier? – Queensland Brain Institute – University of Queensland,” https://qbi.uq.edu.au/brain/brain-anatomy/what-blood-brain-barrier.