Welcome back to Living Well with Lipedema! In this post, I’m going to respond to a recent article published in Frontiers in Nutrition. The article is titled “Ketogenic Diets and Chronic Disease: Weighing the Benefits Against the Risks.” For those who don’t know, a ketogenic diet is a low-carbohydrate, high-fat diet, and we have seen incredible results from this way of eating at Lipedema Simplified. I want to take the time to discuss the paper’s claims and to, hopefully, debunk any fear of the ketogenic diet.
Bias of the Authors
Before discussing the paper’s claims, it is important to know the connections and biases of the authors. All authors in this paper are associated with the Physicians Committee for Responsible Medicine, a known animal rights organization that promotes veganism. Clearly, the bias of the authors is to promote a plant-based diet. They are trying to show that eating animal-sourced foods is unhealthy. Although this article is called a “study” in the mainstream press, it is actually a review of the literature and is the authors’ opinion. It would not be unreasonable for the authors to acknowledge their bias and then perform a clinical trial, but I want to clearly point out that no such trial has been carried out.
Evidence Double Standard
Now, I will dig into the article’s claims. The authors seem to have a double standard with regards to “evidence.” If a study’s outcomes support their claims that a plant-based diet is superior, lower-level evidence is sufficient. When I refer to “lower-level evidence,” examples include epidemiological data, animal research, or a very short-term 2-week clinical trial. However, If the authors’ claims are refuted by the outcomes of a study, then the level of evidence is held to a much higher standard. A three-month study is not long-term enough. If it is a longer-term study, then the authors argue that not having a control group or a lack of randomization renders the results insignificant. Interestingly, studies that meet the highest level of evidence are just given a cursory mention. For example, a six-month study that showed the beneficial effects of a ketogenic diet on diabetes was called “short term”.1 However, the authors also report a two-week intervention that supported the benefits of a plant-based diet as evidence for their claims.2
Epidemiological studies are studies that are merely observational. They ask people what they eat and what health issues they have. These studies are used to demonstrate that people who eat more animal-sourced foods have more health issues, such as non-alcoholic fatty liver disease.3 Association does not prove causation, and it is the lowest form of evidence. But the authors report this outcome as supporting their claims that a plant-based diet is superior. The authors later state that there have been “few clinical trials” (which have a much higher level of evidence than observational studies) and no randomized trials that show that a ketogenic diet can help with cancer, so more research is needed.
Using the Wrong Studies
Although the authors correctly describe a ketogenic diet as less than 50 grams of carbs per day, they still use studies with diets that were too high in carbs to support their claims. For example, at one point, the authors discussed studies that compared the effectiveness of diets for weight loss. The authors chose to report on a meta-analysis that compared low-carb diets to low-fat, plant-based diets. However, half of the studies in the meta-analysis defined “low-carb” as carbohydrates making up 40% of someone’s daily calories, about 130 grams of carbs/day.4 Because this amount of carbohydrate is not even close to the limited amount in a ketogenic diet, this study had no place in this paper.
The authors make several claims that are not supported by known scientific knowledge or by research studies. For example, under the heading “Effects on Nutrient Metabolism,” they state this without any citation: “Protein utilization is also altered on a ketogenic diet; the body shunts as much protein as possible to gluconeogenesis, while the minimum necessary amount is used for tissue repair.” This statement seems to imply that the vast majority of protein will be converted to glucose (or sugar) without the intake of a high level of dietary sugars. Similarly, the statement that the “minimum necessary amount is used for tissue repair” implies that this diversion of resources is barely adequate for keeping tissues healthy. Actually, there is a large body of evidence that muscle mass, wound healing, and bone health is improved on a ketogenic diet.5 6 7 8
Under “Effects on Diet Quality,” the authors state that “Very-low-carbohydrate diets may lack vitamins, minerals, fiber, and phytochemicals found in fruits, vegetables, and whole grains.” This is also not supported in the literature. In fact, there is much more evidence that a completely plant-based diet without any animal-derived foods is more likely to have vitamin and mineral deficiencies. The plant-based diet is more likely to have an increased incidence of chronic disease as well as compromised immune function.9 10 11
The authors also state that “Ketogenic diets are typically low in fiber needed not only for healthful intestinal function but also for microbial production of beneficial colonic short-chain fatty acids, which enhance nutrient absorption, stimulate the release of satiety hormones, improve immune function, and have anti-inflammatory and anti-carcinogenic effects.”
The first part of the statement is outrageous because ketogenic diets usually keep carb intake low by eating only high-fiber vegetables. The second part of the statement implies that a diet low in fiber will consequently result in many negative health outcomes. This could not be further from the truth. There are multiple studies showing that ketogenic diets promote improved bowel health,12 13 better nutrient absorption,14 increased satiation,15 and lower markers of inflammation.16
Keto and Chronic Conditions
The bias of the authors is clearly seen in their discussion of the effects of a ketogenic diet on various chronic conditions. For example, the longest term and most documented use of a ketogenic diet have likely been for epilepsy and type 1 diabetes. Before there was medication to manage either of these conditions, the diet was the only option. Even today with the insulin for diabetes and anti-seizure medications for epilepsy, better management is seen when pharmaceuticals are combined with a ketogenic diet.17 Unfortunately, the influence of plant-based diet proponents caused highly processed seed oils to be the basis of the fat consumed on these early diets. Although seizures were controlled and blood sugar stabilization was achieved, the negative effects directly attributable to these inflammatory oils are reported in the literature. These negative results are used to claim the harmful effects of a ketogenic diet.
The authors try to paint the ketogenic diet as being bad for heart health solely based on the effect of the diet on LDL cholesterol numbers. The hypothesis that claimed that saturated fat is bad for your heart has been thoroughly discredited. All recent research has found no link between saturated fat and heart disease.18 Additionally, LDL cholesterol is no longer considered a reliable marker of heart disease.19 In fact, older people with lower cholesterol don’t live as long as those with higher cholesterol.20 A much better indication of heart disease risk is the ratio between HDL and triglycerides.21
This paper is important for women with lipedema because many women are considering or just starting to use a ketogenic diet to help with their lipedema. The unsubstantiated hyperbole in this paper may keep some women from experimenting with diet to see if it will help manage their symptoms. We are seeing incredible results with this way of eating at Lipedema Simplified. We believe that you should have good science and the guidance of your health care providers to help you decide how to manage your lipedema, not unfounded, inaccurate, and incomplete data that is meant to scare people.
Until next time!
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- Westman EC. Effect of 6-month adherence to a very low carbohydrate diet program. Am J Med. (2002) 113:30–6. doi: 10.1016/S0002-9343(02)01129-4 1
- Hall KD, Guo J, Courville AB, et al. Effect of a plant-based, low-fat diet versus an animal-based, ketogenic diet on ad libitum energy intake. Nat Med. (2021) 27:344–53. doi: 10.1038/s41591-020-01209-1 2
- Alferink LJ, Kiefte-de Jong JC, Erler NS, Veldt BJ, Schoufour JD, de Knegt RJ, et al. Association of dietary macronutrient composition and non-alcoholic fatty liver disease in an ageing population: the Rotterdam Study. Gut. (2019) 68:1088–98. doi: 10.1136/gutjnl-2017-3159403
- Meng Y, Bai H, Wang S, et al. Efficacy of low carbohydrate diet for type 2 diabetes mellitus management: a systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract. (2017) 131:124–31. doi: 10.1016/j.diabres.2017.07.006 4
- Chia-Lin Lee, Shang-Feng Tsai. The impact of protein diet on bone density in people with/without chronic kidney disease: An analysis of the National Health and Nutrition Examination Survey database, Clinical Nutrition. (2020) 39:11, 3497-3503, ISSN 0261-5614, https://doi.org/10.1016/j.clnu.2020.03.014. 5
- Marta Cuenca-Sánchez, Diana Navas-Carrillo, Esteban Orenes-Piñero, Controversies Surrounding High-Protein Diet Intake: Satiating Effect and Kidney and Bone Health, Advances in Nutrition, Volume 6, Issue 3, May 2015, Pages 260–266, https://doi.org/10.3945/an.114.007716 6
- Merra G, Miranda R, Barrucco S, et al. Very-low-calorie ketogenic diet with aminoacid supplement versus very low restricted-calorie diet for preserving muscle mass during weight loss: a pilot double-blind study. European Review for Medical and Pharmacological Sciences. 2016 Jul;20(12):2613-2621. 7
- Shaw DM, Merien F, Braakhuis A, Keaney L, Dulson DK. Adaptation to a ketogenic diet modulates adaptive and mucosal immune markers in trained male endurance athletes. Scand J Med Sci Sports. 2021 Jan;31(1):140-152. doi: 10.1111/sms.13833. Epub 2020 Oct 5. PMID: 32969535. 8
- Isabel Iguacel, María L Miguel-Berges, Alejandro Gómez-Bruton, Luis A Moreno, Cristina Julián, Veganism, vegetarianism, bone mineral density, and fracture risk: a systematic review and meta-analysis, Nutrition Reviews, Volume 77, Issue 1, January 2019, Pages 1–18, https://doi.org/10.1093/nutrit/nuy045 9
- Dagnelie, P. C. [Nutrition and health—potential health benefits and risks of vegetarianism and limited consumption of meat in the Netherlands]. Ned. Tijdschr. Geneeskd. 147, 1308–1313 (2003) 10
- Hibbeln, J. R., Northstone, K., Evans, J. & Golding, J. Vegetarian diets and depressive symptoms among men. J. Affect. Disord. 225, 13–17 (2018). 11
- Cohen, S. A. et al. Clinical and mucosal improvement with specific carbohydrate diet in pediatric Crohn’s disease. J. Pediatr. Gastroenterol. Nutr. 59, 516–521 (2014). 12
- Olendzki, B. C. et al. An anti-inflammatory diet as treatment for inflammatory bowel disease: A case series report. Nutr. J. 13, 5 (2014). 13
- Donnellan, C. F., Yann, L. H. & Lal, S. Nutritional management of Crohn’s disease. Ther. Adv. Gastroenterol. 6, 231–242 (2013). 14
- Alexandra M Johnstone, Graham W Horgan, Sandra D Murison, David M Bremner, Gerald E Lobley, Effects of a high-protein ketogenic diet on hunger, appetite, and weight loss in obese men feeding ad libitum, The American Journal of Clinical Nutrition, Volume 87, Issue 1, January 2008, Pages 44–55, https://doi.org/10.1093/ajcn/87.1.44 15
- Dupuis, N., Curatolo, N., Benoist, J.-F., & Auvin, S. (2015). Ketogenic diet exhibits anti-inflammatory properties. Epilepsia, 56(7), e95–e98. doi:10.1111/epi.13038 16
- Dressler, A., Reithofer, E., Trimmel-Schwahofer, P., Klebermasz, K., Prayer, D., Kasprian, G., … Feucht, M. (2010). Type 1 diabetes and epilepsy: Efficacy and safety of the ketogenic diet. Epilepsia, 51(6), 1086–1089. doi:10.1111/j.1528-1167.2010.02543.x 17
- Robert Hoenselaar, Saturated fat and cardiovascular disease: The discrepancy between the scientific literature and dietary advice, Nutrition, Volume 28, Issue 2, 2012, Pages 118-123, ISSN 0899-9007, https://doi.org/10.1016/j.nut.2011.08.017. 18
- Dugani SB, Moorthy MV, Li C, et al. Association of Lipid, Inflammatory, and Metabolic Biomarkers With Age at Onset for Incident Coronary Heart Disease in Women. JAMA Cardiol. 2021;6(4):437–447. doi:10.1001/jamacardio.2020.7073 19
- Irwin J Schatz, Kamal Masaki, Katsuhiko Yano, Randi Chen, Beatriz L Rodriguez, J David Curb, Cholesterol and all-cause mortality in elderly people from the Honolulu Heart Program: a cohort study, The Lancet, Volume 358, Issue 9279, 2001, Pages 351-355, ISSN 0140-6736, https://doi.org/10.1016/S0140-6736(01)05553-2. 20
- Morrison A, Hokanson JE. The independent relationship between triglycerides and coronary heart disease. Vasc Health Risk Manag. 2009;5(1):89-95. 21