Talk:Ketogenic diet

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This article is not about "ketogenic diet", it is about its use in medicine.

I think there should be first at the very top a very short definition of the diet itself all alone, without connecting it to one specific use.

This should be followed by the general discussions of the chemical reactions in the body, then should come its variants described in laymans terms, and the different reasons ketogenic diet is actualised, such as its applications against things we face today. The ketogenic diets use as a cure for childhood epilepsy must be there for sure, but one should recognize that there are many other reasons ketogenic diet is being discussed, argued for-and-against, practiced, found useful, found it should be avoided in certain situations, etc.. These should be listed early and given their own chapters on equal footing. The list is long: weight control, diabetes, sport, evolutionary advantage, its disappearance from common practice in recent history, degrees/phases of ketogenesis, relationship to other bodily functions, methods-, techniques- and tools for its practice.

I am tending to believe that we need several supporting pages; May be we need a new page with this name for the LCAPHF diet, and the present page sould be renamed "Ketogenic Diet Therapy". Cobanyastigi (talk) 20:05, 5 June 2019 (UTC)

The reason why this article is about epilepsy treatment aspects of the ketogenic diet is because that reflects the balance of reliable sources in the real world. There is also an article on ketosis. The discussion of the "keto" diet as a weight-loss fad/lifestyle choice is at Low-carbohydrate diet. Alexbrn (talk) 01:29, 6 June 2019 (UTC)

This is the only use of a ketogenic diet with convincing evidence of efficacy and safety, though it requires considerable medical supervision from a neurologist and dietitian. It has been used for nearly 100 years for epilepsy and might well be used for another 100 since we are no closer to understanding its mechanism or finding a way of achieving this effect in a pill. Whereas extreme low-carb high-protein diets, which achieve a degree of ketosis but not under medical supervision, became fashionable in 2018 and it is too soon to know if they are anything more than a fad. Certainly there is increasing evidence of the importance of fibre in one's diet, which is sorely lacking in a ketogenic diet. Please read the various talk archives about this. None of our reliable sources take the approach you suggest. -- Colin°^Talk 21:18, 6 June 2019 (UTC)

This diet is also recommended for people with certain Glycogen storage diseases, it's not just for treating epilepsy. The page takes the title of 'Ketogenic diets' and dedicates the topic to 'Ketogenic diets for the treatment of epilepsy'. Would it be cool to add a section talking broadly about the effect of ketogenic diets in GSDs? Ramiel~enwiki (talk) 06:25, 7 January 2020 (UTC)

KD Applications for Diabetics

I have had type 2 diabetes since the last decade. Havnen't been able to keep it in remission. Recently got YouTube recommended videos to watch. Two people: Dr. Berry and ? (Beat Diabes) say that a Ketogenic Diet can have massive positive effects on Type 2 Diabetes. This article doesn't really mention that. It focuses instead on the application for healing/reversing Epilepsy. Dr. Berry's YouTube channel: https://www.youtube.com/channel/UCIma2WOQs1Mz2AuOt6wRSUw

Beat Diabetes https://www.youtube.com/channel/UCmKsQWqGmDPIWgrVqGYbc3w

So a section on the application of a Ketogenic Diet on Diabetics is in store. Jimj wpg (talk) 07:00, 18 November 2019 (UTC)

Jimj wpg, various low-carb diets have been trialled for diabetes. Some of these low-carb diets are ketogenic (or are ketogenic in their initial phase) but they differ quite a lot from the diet this article discusses, which has been around for 100 years to treat epilepsy. The article you want is Low-carbohydrate diet, which has some mention of KD. --Colin°^Talk 10:30, 21 November 2019 (UTC)

add gamma delta T cell association ?

• Ketogenic diet activates protective γδ T cell responses against influenza virus infection Science Immunology 15 Nov 2019: Vol. 4, Issue 41, doi:10.1126/sciimmunol.aav2026 Sciencemag.org

X1\ (talk) 23:05, 20 November 2019 (UTC)

X1\ we don't normally mention rat or mice experiments on Wikipedia or directly cite research papers. See WP:MEDRS. If something comes of this research that has meaning for humans, then there will be papers and other articles for us to cite in whichever article is appropriate. --Colin°^Talk 10:34, 21 November 2019 (UTC)

A minority opinion

While historically (since 1921), ketogenic diets have been used to treat epilepsy, contemporary usage to treat obesity and type 2 diabetes mellitus is far more common. Research and clinical experience indicate that a ketogenic diet is more effective at controlling the high blood sugars of diabetes than are current diabetes medicines (more on this below).

I have Type 2 diabetes mellitus, and have found like other patients that a ketogenic diet (a diet that induces ketosis, a form of metabolism that obtains energy from oil and fat in the diet instead of sugar and starch) will control diabetes effectively without the need for increasing use of diabetic medicines over time (details and research results are discussed toward the end of this comment).

I believe that a major contribution to public health would result from educating everyone concerning the use of a ketogenic diet as an alternative to an ever-increasing need for diabetic medicines in patients who are in glycolysis (normal carbohydrate-burning metabolism). Diabetic medicines are typically increased over time as the disease progresses (and the body's insulin resistance increases and pancreatic function decreases).

Details and Research

Ketosis is a unique form of metabolism, which can be induced by diet. This has been known since 1921 when the ketogenic diet was first standardized at Mayo Clinic to treat certain forms of epilepsy.

The contemporary use of a ketogenic diet to treat obesity, diabetes, and certain other diseases is medically controversial due to the following factors:

1. A similarly-named but different condition, ketoacidosis, is life-threatening; it is common to blame ketosis (which is simply a form of metabolism and is medically benign) for generating ketoacidosis, which it does not do, or for itself having the effects of ketoacidosis, which it does not have.

2. The definition of a ketogenic diet has been misunderstood in various ways (such as a diet containing less than 5% carbohydrates, which may or may not generate ketosis, depending on the individual).

3. There has been an enthusiastic rush to publish research which has resulted in several negative poor-quality studies being published (in some of these studies, the subjects were not measured for being in ketosis).

4. It is relatively difficult to obtain funding, since ketosis results in less drug usage rather than the need for a specific pharmaceutical.

While patient response to being in ketosis is seen to be dramatically positive in a number of studies (in terms of the reversal of obesity and/or the elimination of the need for medications to obtain diabetic control), and while measuring ketosis is not difficult since it is produces dramatically different physiological markers from the usual glycolysis, ketogenic diets are not yet recommended by doctors, dietitians, and nutritionists as standard practice due to the many common misunderstandings and the poor meta studies reflecting the many poor studies that have been published to date.

Here are some studies and meta studies of true ketogenic diets and their results in diabetes:

• A low-carbohydrate, ketogenic diet to treat type 2 diabetes (https://link.springer.com/article/10.1186/1743-7075-2-34):

"[A ketogenic diet] had positive effects on body weight, waist measurement, serum triglycerides, and glycemic control in a cohort of 21 participants with type 2 diabetes. Most impressive is that improvement in hemoglobin A1c was observed despite a small sample size and short duration of follow-up, and this improvement in glycemic control occurred while diabetes medications were reduced substantially in many participants."

• Benefits of Ketogenic Diet for Management of Type Two Diabetes: A Review (https://obesity.imedpub.com/benefits-of-ketogenic-diet-for-management-of-type-two-diabetes-a-review.php?aid=14629):

"The prevalence of type two diabetes (T2D) has been increasing sharply worldwide. Many recent studies have been done to determine the effective strategies for better management of type two diabetes. One of these strategies was the Ketogenic Diet, which when performed on rats and human showed very impressive results. The benefits of having some ketone bodies circulating in the body have numerous benefits such as weight loss, improvement of HbA1c levels, reversal of nephropathy, cardiac benefits and treatment for dyslipidemia."

• Implementing a low-carbohydrate, ketogenic diet to manage type 2 diabetes mellitus (https://www.ncbi.nlm.nih.gov/pubmed/30289048):

"Reducing carbohydrate intake to a certain level, typically below 50 g per day, leads to increased ketogenesis in order to provide fuel for the body. Such low-carbohydrate, ketogenic diets were employed to treat obesity and diabetes in the 19th and early 20th centuries. Recent clinical research has reinvigorated the use of the ketogenic diet for individuals with obesity and diabetes. Although characterized by chronic hyperglycemia, the underlying cause of T2DM is hyperinsulinemia and insulin resistance, typically as a result of increased energy intake leading to obesity. The ketogenic diet substantially reduces the glycemic response that results from dietary carbohydrate as well as improves the underlying insulin resistance. This review combines a literature search of the published science and practical guidance based on clinical experience."

Note: I am an independent researcher in an unrelated field, and my interest in ketosis is as a patient and successful user of a ketogenic diet, not as a researcher.

Note: The usage of so-called keto dieting in musclebuilding and sports is a separate social phenomenon and is irrelevant to the main importance to society of true ketogenic diets in the management of obesity and type 2 diabetes.

David Spector (talk) 13:29, 5 May 2020 (UTC)

You write "contemporary usage to treat obesity and type 2 diabetes mellitus is far more common". Citation required! This seems an extraordinary claim, since from the literature it seems the ketogenic diet for weight-loss is regarded as almost a domain of crankery/pseudoscience. The use of all sort of LC diet for weight loss is discussed at Low-carbohydrate diet where the modern science is quite thoroughly cited. Alexbrn (talk) 13:36, 5 May 2020 (UTC)

Headbomb's script for flagging non-reliable sources is producing a big fat red no-no for https://obesity.imedpub.com/benefits-of-ketogenic-diet-for-management-of-type-two-diabetes-a-review.php?aid=14629 SandyGeorgia (Talk) 13:38, 5 May 2020 (UTC)

Yes indeed, the Journal of Obesity & Eating Disorders is a predatory journal. Alexbrn (talk) 13:39, 5 May 2020 (UTC)

Well, I suppose it's a good thing that Headbomb made it so glaring when the source is so bad, but it sure makes for obnoxious reading on this talk page! SandyGeorgia (Talk) 13:42, 5 May 2020 (UTC)

I think it is a bit unfair to claim that ketogenic diet for weight-loss or diabetes is all crankery, though its lay popularity is out of proportion to the evidence. There are proper scientists who have conducted research into very low carbohydrate diets for either weight loss or diabetes control. A problem, as has been discussed on these pages before, is that such diets do tend to be quite different to the KD for epilepsy, often with high protein, and are generally aimed at a middle-aged population rather than children. There is also the sport usages, and the ongoing research into its use for treating other neurological conditions (which remains at the research stage but may well bear fruit). So I think that wrt weight lost / adult health / sport that Low-carbohydrate diet remains the best place to document those.

While the "Classic" ketogenic diet has split into four commonly-used variants, some of which are less ketogenic in their primary aim, those studying and providing such therapies continue to use the term "Ketogenic dietary therapies", rather than just "dietary therapy for epilepsy".

I think this topic is quite distinct from other diets that may or may not be ketogenic to some degree, are different in their proportion of food elements, and are aimed at a different population and purpose. That suggests the article should not become a mix of all such "keto diets" but that Wikipedia deals with them separately. Those studying sport fitness or diabetes control make no more than passing mention of the diet variants for epilepsy control: the literature does not combine them. There is often on Wikipedia a situation where different subjects may be naturally given the same article title, and we can only have one. At the present time, the ketogenic diet for epilepsy is the only therapy with strong evidence and clinical-guideline recommendations and 100 years of medical use. So its case for remaining the default topic for this article title remains solid IMO. -- Colin°^Talk 19:59, 15 May 2020 (UTC)

I think that David Spector is correct that low-carb diets are much more popular now for diabetes than they used to be, and some recommend restricting carb intake until ketone production can be easily measured at home. However, that doesn't mean that they're on the same diet as the kids with epilepsy. I'd be willing to bet fairly large sums of money that David's healthcare providers would not recommend that any diabetic limit their fruit and vegetable intake to no more than two ounces total per day, and yet that's what the sample diet in the article does: just half an ounce of fruit, and 1.5 ounces of low-carb vegetables for the whole day. WhatamIdoing (talk) 18:57, 21 May 2020 (UTC)

Healthcare providers generally know "ketosis" only as a specialized and medically accepted metabolic state for treating epilepsy, or else have patients who report its value in controlling type 2 diabetes or in normalizing body weight.

I doubt that many healthcare providers would venture any opinion as to how much vegetable matter should be in a patient's diet. Neither would experts in ketogenic diet, since what matters for achieving ketosis is carbohydrate and fat levels, not specific kinds of foods such as vegetables. Vegetables, in particular, range from high in carbohydrates (potatoes) to low in carbohydrates (lettuce).

A ketogenic diet suitable for the control of diabetes generally does not focus on specific foods or amounts of foods as good, bad, or recommended. The state of ketosis generally results from very low carbohydrate intake in combination with normal or elevated amounts of fats and oils, since these are metabolized for energy in ketosis. Protein levels are not of primary significance in achieving ketosis, and slightly higher protein levels are encouraged, as are high levels of non-nutritive fiber, both soluble and insoluble.

The whole field of ketogenic diet for treating diabetes and circulatory problems is still quite new, and misunderstandings outside of its clinical and research community are common (usually starting with the common confusion with ketoacidosis). Many doctors doing current research in ketosis post videos at YouTube in an attempt to alert the public to an alternative for ever-increasing medication to counter the phenomenon of ever-increasing insulin resistance, which frequently happens in type 2 diabetes, and as an intervention for the current epidemic in obesity.

So the best way to locate good studies of patient populations having success with ketogenic diets is to start at YouTube to find out which clinics are doing these studies, then looking up reports and publications. While I've seen some of these videos, and they are certainly medically impressive, I don't have the time to create a research bibliography; but one is urgently needed.

I actually started my own diet on the advice of a cardiologist whom I saw briefly, who was impressed with the research results on ketosis in his own field, on heart and circulatory health, and had educated himself about the rich information published on ketosis and diet in the treatment of obesity, type 2 diabetes, and cardiac health.

I have discussed the value of a ketogenic diet with my family doctor, my oncologist, my surgeons, several dieticians, my nephrologist, and other specialists. Not one of these medical people knew anything about ketosis or ketogenic diet other than rumors from patients. I would say that medicine has not yet discovered the immense value of ketogenic diets for conditions outside of epilepsy.

And yes, the ketogenic diet used for the treatment of epilepsy is quite different from the ketogenic diet that controls type 2 diabetes and certain other conditions. The kind of diet I maintain is actually pretty easy to do.

It was up to me to experiment on my own and discover that when I was in ketosis (as measured by Ketostix or by examining the urine--I haven't purchased a ketone breath or blood meter) my blood glucose is under good control, and when my intake of carbohydrates is just high enough to take me out of ketosis my blood glucose goes way too high and stays there all day, even at happening at a time when I was taking 2000 mg of metformin a day.

These experiences of mine match those reported by several clinicians who run ketogenic diet trials to reverse escalation in insulin dosages for dozens or hundreds of patients with advanced type 2 diabetes. Their reported success rates are high.

Wikipedia is for reporting accepted and notable knowledge and human experience, not novel medical treatments. Ketosis and ketogenic diets as used in the treatments for the conditions listed above are just now beginning to cross over the threshold for being relevant subjects for inclusion here. This is why this section is titled A Minority Opinion. Someday, much of what I've written here may become a majority opinion. David Spector (talk) 20:02, 21 May 2020 (UTC)

I believe you will find that healthcare providers and medical organizations have been recommending that everyone eat at least 400 grams of fruits and vegetables (not counting potatoes and similar foods) for quite a number of years, and that people with diabetes are routinely encouraged to eat more than that. WhatamIdoing (talk) 22:19, 21 May 2020 (UTC)

WhatamIdoing: What are you doing? I have not disagreed with your statement. However, it has nothing to do with this topic. Eating a certain amount of a particular food will most definitely not induce ketosis. David Spector (talk) 11:55, 22 May 2020 (UTC)

David Spector, I encourage you to read through the archives of this article talk page. I would love someone to improve our content about very low carb diets for weight loss / diabetes control. Some researchers have used the term "very low carbohydrate ketogenic diet" which may catch on, but at the moment this research is complicated by having no one definition of a diet. Even the epilepsy KD is complicated with now four or five variants, each taking a different approach to measuring or counting foodstuffs and quantities. The main research has been on the Classic KD, and I'm not aware the others have been studied nearly as well, other than to demonstrate they can be equivalent in some patient populations. I think the main problem with all diets is sticking with it: most children on the KD do not tolerate it for long and that's even more of a problem for adolescents and adults. Some of the more recent variants are designed to be more tolerable but are still pretty restrictive. (People who are fed by tube don't have this issue, once any gastro issues are resolved). My understanding of adult diets for weight loss is that it is important to find one you can stick with, and that doesn't remove important nutrients from your diet, but that otherwise the evidence that one is superior to another is weak. But this topic I feel really belongs in another page on Wikipedia. -- Colin°^Talk 07:49, 22 May 2020 (UTC)

Colin, as I indicated above, I have little time to work on this. Not even enough time to read the archives and comment on them intelligently. Besides, I'm actually not an expert, just someone who uses this diet successfully and has heard of several small and medium-scale studies showing that type 2 diabetes patients on high-dosage insulin can successfully titrate down and eliminate all diabetes drugs. Such patient experience and (tiny amount) of research deserves some mention, hence my "minority opinion". But extending this article for the new applications calls for contributions by an expert.

As to the confusions here and elsewhere about what constitutes a "ketogenic diet", I fully agree: we need better terminology, because these diets aren't going away.

Concerning the difficulty of staying on this or any other diet, I agree that it is a very important issue. I actually started my diet twice: the first version was too difficult for me to maintain for longer than a few months. But my second version has served me well and is not so difficult to maintain, as I mentioned above.

The kind of diet required to reverse insulin resistance or obesity does not require weighing and measuring food, or ingesting large amounts of fat. All that is necessary for successful results is staying in ketosis, as evidenced by some sort of measurement. It seems evident that epilepsy is much more difficult to treat than these other disorders through a ketogenic diet, so the diet must be more severe for epilepsy.

Also, I hope everyone remembers that even though this use of ketogenic diets is perhaps only about 15 years old, it has had a very slow start among medical specialists, with almost no external publicity other than for the faddish "muscle-building" usage, which appears medically unresearched. David Spector (talk) 11:55, 22 May 2020 (UTC)

New sources

• Kossoff, EH; Zupec-Kania, BA; Auvin, S; Ballaban-Gil, KR; Christina Bergqvist, AG; Blackford, R; Buchhalter, JR; Caraballo, RH; Cross, JH; Dahlin, MG; Donner, EJ; Guzel, O; Jehle, RS; Klepper, J; Kang, HC; Lambrechts, DA; Liu, YMC; Nathan, JK; Nordli DR, Jr; Pfeifer, HH; Rho, JM; Scheffer, IE; Sharma, S; Stafstrom, CE; Thiele, EA; Turner, Z; Vaccarezza, MM; van der Louw, EJTM; Veggiotti, P; Wheless, JW; Wirrell, EC; Charlie, Foundation.; Matthew's, Friends.; Practice Committee of the Child Neurology, Society. (June 2018). "Optimal clinical management of children receiving dietary therapies for epilepsy: Updated recommendations of the International Ketogenic Diet Study Group". Epilepsia open. 3 (2): 175–192. doi:10.1002/epi4.12225. PMID 29881797.

An update to the existing ref #9. Hopefully most citations can be moved over to this new guideline, though some may need modifying, and some additional recommendations may be warranted. This is the most important source: consensus recommendations by world experts reviewing the research and clinical experience.

• Husari, Khalil S.; Cervenka, Mackenzie C. (May 2020). "The ketogenic diet all grown up—Ketogenic diet therapies for adults". Epilepsy Research. 162: 106319. doi:10.1016/j.eplepsyres.2020.106319.

Adult epilepsy.

• van der Louw, Elles; van den Hurk, Dorine; Neal, Elizabeth; Leiendecker, Bärbel; Fitzsimmon, Georgiana; Dority, Laura; Thompson, Lindsey; Marchió, Maddelena; Dudzińska, Magdalena; Dressler, Anastasia; Klepper, Joerg; Auvin, Stéphane; Cross, J. Helen (November 2016). "Ketogenic diet guidelines for infants with refractory epilepsy". European Journal of Paediatric Neurology. 20 (6): 798–809. doi:10.1016/j.ejpn.2016.07.009. PMID 27470655.
• Infants. European guidelines.
• Blackford, R (May 2020). "Not your parents' ketogenic diet - Flexibility in 2020". Epilepsy research. 162: 106307. doi:10.1016/j.eplepsyres.2020.106307. PMID 32163829.

Commentary on changes over last decade or so.

• Höhn, S; Dozières-Puyravel, B; Auvin, S (December 2019). "History of dietary treatment from Wilder's hypothesis to the first open studies in the 1920s". Epilepsy & behavior : E&B. 101 (Pt A): 106588. doi:10.1016/j.yebeh.2019.106588. PMID 31677579.

Early history

• Cai, QY; Zhou, ZJ; Luo, R; Gan, J; Li, SP; Mu, DZ; Wan, CM (December 2017). "Safety and tolerability of the ketogenic diet used for the treatment of refractory childhood epilepsy: a systematic review of published prospective studies". World journal of pediatrics : WJP. 13 (6): 528–536. doi:10.1007/s12519-017-0053-2. PMID 28702868.

Review

• van der Louw, E; Aldaz, V; Harvey, J; Roan, M; van den Hurk, D; Cross, JH; Auvin, S; Review, Group. (January 2020). "Optimal clinical management of children receiving ketogenic parenteral nutrition: a clinical practice guide". Developmental medicine and child neurology. 62 (1): 48–56. doi:10.1111/dmcn.14306. PMID 31313290.

Ketogenic parenteral nutrition

-- Colin°^Talk 20:06, 15 May 2020 (UTC)