by Dr Matthew Chircop
Prolonged (life-long) ketogenic diets have been in use for the treatment of intractable epilepsy (epilepsy which does not respond to treatment with medications). People outside of medicine have been using them as a temporary measure for weight-loss at least since Robert Atkins popularised this form of diet in the 1960s. The CSIRO's most recent healthy diet book has, perhaps controversially, recommended a form of temporary ketogenic diet. Does this mean that ketogenic diets are safe in the long term?
Yes. And no.
Ketogenic diets were originally designed to be used under the close supervision of specially trained doctors and nutritionists. The patient requires regular monitoring to ensure that dehydration and electrolyte disorders are rapidly detected and treated. When used for short periods they do result in weight loss. Even the CSIRO’s recent publication admitted that the end results are not significantly different from a standard calorie-restricted diet (which had a low amount of fat and moderate amounts of carbohydrate).
So what is the problem with a ketogenic diet?
I have a number of concerns regarding the current trend towards adopting a ketogenic diet. The current guidelines, with regard to diets, are to establish a diet which is sustainable and varied. By their very nature, ketogenic diets are restrictive. An entire macronutrient is effectively banned. The replacement of fat in foods for sugar has not done us any favours, so I would be extremely cautious about essentially replicating the same mistake (i.e. swapping large amounts of one macronutrient for another).
The use of ketogenic diets for weight-loss (in special circumstances) is regarded by doctors and nutritionists as a temporary measure, not a life-long strategy for health. The long-term use of a ketogenic diet in patients with intractable epilepsy is not without it’s problems. These include (but are not limited to) high cholesterol levels, low bone mineral density (with increased risk of fractures due to otherwise minor injury), menstrual irregularities (with increased risk of infertility), growth disruption in children, and depression. In the case of people with treatment-resistant epilepsy, there is very little choice.
Basically, ketogenic diets are designed to “trick” your body into starvation, whereby fat becomes the primary fuel source for the body. During this time, energy is relatively conserved – the body stops doing certain functions which are not immediately important for survival (such as maintaining bone strength, hair growth, nail growth, fertility, growth in children etc). Needless to say, starvation is not a state in which the body thrives.
The evidence regarding lasting weight-loss is compelling. Those people who succeed in keeping the weight off have made permanent changes to their diet (sustained reduction in calorie intake) and physical activity levels. From comfort, variety and adherence perspectives, the easiest diet to adopt is a diet which simply moderates the individual’s intake of protein, carbohydrate and fat, thereby reducing calorie intake overall. This can be achieved by combining low calorie-density meals with portion control, with provisions to occasionally relax these conditions as desired (and tolerated). Adequate amounts of lean protein is required to prevent significant muscle loss. Moderate amounts of dietary carbohydrate help with maintaining mood and energy levels, which are likely to improve the intensity of physical activity (which has been shown to positively correlate with long-term changes in body composition) and adherence to exercise. A minimal amount of fat is required for food palatability and health.
Whilst people can adapt to ketogenic diets, the temporary reduction in mental and physical performance (along with other unpleasant side effects) could potentially contribute to subjects developing an aversion to diet modification and increased physical activity. Most people do not need to go through the uncomfortable transition of a ketogenic diet in order to sustainably lose weight.
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