Quick Summary tl;dr
Keto is not a fad. It is rebranding of evolution.
Therapeutic Carbohydrate Restriction (TCR) can have benefits without practitioners having to go all-in keto.
While diet is individual, a keto diet and other forms of Therapeutic Carbohydrate Restriction should be provided as an option for obesity and metabolic disease, especially because a vanishing small number of Americans are metabolically healthy.
There is no medicine without metabolism.
The keto diet is often brushed off as a fad diet, but nothing could be further from the truth.
The keto diet is so named because it relies on carbohydrate restriction to shift the body’s metabolism into a fat-burning mode, a state in which the liver also turns some fat into molecules called ketone bodies.
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Keto is Rebranding for the Oldest Human Diet
This shift to a fat — and ketone — dependent metabolism was central to our evolution as a species.
During evolution, our species underwent periods of food deprivation, and plentiful stores of carbohydrates were rarely available. But, while the body can only store about 450 Calories as freely available carbohydrate energy in the form of liver glycogen, our fat stores are nearly unlimited. Even a relatively lean person has 100,000 stored fat Calories.
Ketosis is a state in which the potential to use those fat Calories to fuel the body and, in particular, the brain is maximized. This “fad” diet gets its name from the fact that we now know about ketone bodies (a “digestible” form of fat for neurons, brain cells).
The keto diet is just a rebranding for the oldest human diet.
The keto diet is just a rebranding for the oldest human diet.
Therapeutic Carbohydrate Restriction
Admittedly, our goals in the 21st century are distinct from our goals thousands of years ago. Famine is less of an issue and feasting is the danger. In this new environmental context, does the keto diet have any place?
The short answer is, “Yes.” Today the most daunting ongoing medical challenges in the United States are metabolic disease, including obesity, diabetes, heart disease, metabolic syndrome, and Alzheimer’s disease. By mid-century, the number of people living with each diabetes and Alzheimer’s in the United States is projected to triple.
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The keto diet has a broad potential to aid what ails us.
The benefits for certain diseases, including obesity and diabetes, depend primarily on Therapeutic Carbohydrate Restriction (TCR). The keto diet is, by nature, a low-carb diet.
Decreasing carbohydrates in the diet prevents spikes and drops in the hormone insulin. These spikes and drops, colloquially termed “the insulin roller coaster,” drive a form hormonal hunger in which the body is tricked into desiring food (usually in the form of carbohydrates), not to fulfill a nutritional need, but to quench a craving.
This is one way in which the diet can be an excellent weight loss tool. It erases the insulin roller coaster to decrease maladaptive hunger while simultaneously adapting the body to relying on its own fat as a fuel source.
Furthermore, reducing carbohydrates and diminishing the insulin roller coaster improves insulin resistance, a fundamental pathology in type II diabetes ( Athinarayanan et al. 2019). It’s unsurprising that multi-year studies have demonstrated the keto diet is an excellent option for reversing diabetes. ( Athinarayanan et al. 2019, Unwin D. et al. 2020)
Importantly, to gain the weight loss and diabetes reversing benefits of keto, one need not necessarily go all-in.
While a proper keto diet definitionally requires ketone bodies to rise above a certain level, most laypeople don’t practice keto in this way. Therapeutic Carbohydrate Restriction is a spectrum and patients struggling with conditions that would benefit from TCR should be encouraged to find a carb-appropriate diet for their needs.
The benefits for other diseases, mental illnesses and neurological diseases including epilepsy and Parkinson's Disease, may also depend on ketone bodies themselves. These biomolecules are not only clean and efficient sources of fuel but potent signaling molecules. They bind receptor on and within cells, alter enzymatic pathways, and even change the way our genetic code is expressed. Through these signaling mechanisms, ketones alter metabolism to improve the fundamental pathologies (like oxidative stress and inflammation) that generally underly metabolic diseases. ( Norwitz et al 2019)
Carbs, especially refined carbs & snacking, stimulates the insulin roller coaster to drive hormonal hunger, not to fulfil a nutritional need, but to quench a craving.
Unwarranted Fear of Cholesterol
The final defence of those who feel most comfortable sticking with the status quo nutritional advice is often that low-carb diets, which are necessarily high in fat, can increase levels of “bad” LDL cholesterol. Firstly, this happens only in a minority of individuals. And, when it does happen, the overall increase in LDL is primarily or completely driven be an increase in large healthy LDL, not small dense 'bad' LDL.
To get on my nutrition soapbox for a moment, since when was nutrition actually as simple as you are what you eat?
As another example, you might think that eating more saturated fat in place of carbohydrates would increase the saturated fat in your blood. As a matter of fact, it doesn’t. A randomized crossover controlled trial — the gold-standard for nutrition research — demonstrated that when participants ate a high-fat, low-carb diet they ended up with far less saturated fat in their blood than when they ate an isocaloric lower-fat, higher carb diet. This was despite that fact that on the low-carb diet they ate 2.5-times more saturated fat ( Parker N Hyde et al. 2019).
Even were saturated fat artery-clogging, these and other data strongly suggest it’s the butter, not the bread, that should remain on the table.
Here’s another important question. How is the status quo nutritional advice working for us?
Keto is Unfairly Vilified
A recent U.S. News and World Report article ranking the most popular diets ranks the keto diet in dead last, 39th, place for health. It states “enthusiasm outpaces evidence.” The insinuation that low-carb and ketogenic diets lack a strong evidence base, as compared to other diets ranked higher on the list, is — quite frankly — a lie.
The report’s rankings demonstrate a lack of understanding of metabolism and an ignorance of the evidence. For example, the Biggest Loser Diet is ranked in the middle of the list, seventeen positions above the keto diet. The former results in a slowing of metabolic rate and leaves an obesogenic fingerprint on the individual, as do most unsustainable crash diets. Maybe that’s why there are no Biggest Loser reunions? By comparison, carbohydrate restriction can protect or increase metabolic rate (Cara B Ebbeling), and is proven to be sustainable when properly formulated.
A survey of the evidence is telling. While there are dozens of randomized controlled trials supporting low-carb and ketogenic diets for weight loss, diabetes, neurological diseases, and other metabolic diseases, there are a sparse few for vegetarian or vegan diets and zero for other diets on the list, like the Noom diet or Dr. Weil’s diet. That’s not to disparage these diets. It’s simply to say that, in terms of evidence base, there is no stronger diet than a keto diet.
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