Ketosis

xyzzy said:

What is often forgotten and overlooked in the argument as to if Ketogenic diets are safe is that they are recommended and treated as long term safe in other fields of medicine that are not particularly related to diabetes or diet.

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Thats strange as I read only yesterday that juvenile epilepsy treated by low carb diets was actually quite rare and only considered when drugs had proved ineffective so we're talking about a relatively small number of children, and that most children were on the diet for a year or less. And for that reason there was no long term research carried out. It is thought that ketones have some effect on the part of the brain responsible for seizures, though it is not fully understood. Long term however the resticted insulin caused retarded growth problems, not good in children, bone fractures and kidney stones were also common.

Quote from Wikipedea, just found it:
Long-term use of the ketogenic diet in children increases the risk of retarded growth, bone fractures and kidney stones.[4] The diet reduces levels of insulin-like growth factor 1, which is important for childhood growth. Like many anticonvulsant drugs, the ketogenic diet has an adverse effect on bone health. Many factors may be involved such as acidosis and suppressed growth hormone.[35] About 1 in 20 children on the ketogenic diet will develop kidney stones (compared with one in several thousand for the general population). A class of anticonvulsants known as carbonic anhydrase inhibitors (topiramate, zonisamide) are known to increase the risk of kidney stones, but the combination of these anticonvulsants and the ketogenic diet does not appear to elevate the risk above that of the diet alone.[36] The stones are treatable and do not justify discontinuation of the diet.[36] Johns Hopkins Hospital now gives oral potassium citrate supplements to all ketogenic diet patients, resulting in a sevenfold decrease in the incidence of kidney stones.[37] However, this empiric usage has not been tested in a prospective controlled trial.[8] Kidney stone formation (nephrolithiasis) is associated with the diet for four reasons:[36]

1. Excess calcium in the urine (hypercalciuria) occurs due to increased bone demineralisation with acidosis. Bones are mainly composed of calcium phosphate. The phosphate reacts with the acid, and the calcium is excreted by the kidneys.
2. Hypocitraturia: the urine has an abnormally low concentration of citrate, which normally helps to dissolve free calcium.
3. The urine has a low pH, which stops uric acid from dissolving, leading to crystals that act as a nidus for calcium stone formation.
4. Many institutions traditionally restricted the water intake of patients on the diet to 80% of normal daily needs;[36] this practice is no longer encouraged.

In adults, common side effects include weight loss, constipation, raised cholesterol levels and, in women, menstrual irregularities including amenorrhoea.

So seems to back up what I read yesterday.

I also read that it was difficult to stay in ketosis for longer than six to twelve months without reducing the amount of protein as well as carbs as after this time the body, which doesnt actually like being in ketosis, tends to start using the protein source for its energy.

So on the one hand we have Dr. Eric Kossoff and Dr Stephen Phinney and Dr Jeff Volek saying that ketogenic diets are safe, and on the other hand we have a charity website saying that "ketosis can lead to death".

I presume, quite rightly, that the aim of that website is to discourage parents from putting their children on a ketogenic diet without medical advice.

catherinecherub said:

"There has to be a rigid, mathematically calculated, supervised diet". How many people here fall into that category?

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Carbs <50g Protein < 18%
Does that count as mathematically calculated? The only maths involved is limiting your intake of these two macronutrients. If you get the maths wrong you won't be in ketosis.

catherinecherub said:

The ketogenic diet must never be undertaken without the correct medical and nutrition supervision. The risks of an unsupervised diet can result in malnutrition, chemical imbalance, vitamin deficiency and may even result in death". Would you say that you need that level of intervention?

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Let's get this straight. The risks of an unsupervised ketogenic diet is death? Since when has anyone died of ketosis?

You can't die of ketosis... it's a defence against starvation. I've no idea what a "chemical imbalance is".It hardly seems scientific does it?

and no doubt Scurvy too is on the list somewhere but I'm not investing in a Lime Grove just yet!

Sid Bonkers said:

Quote from Wikipedea, just found it:
Long-term use of the ketogenic diet in children increases the risk of retarded growth, bone fractures and kidney stones.[4]

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Don't put your kids on ketogenic diets people...

http://en.wikipedia.org/wiki/Complicati ... s_mellitus

borofergie said:

Don't put your kids on ketogenic diets people...

http://en.wikipedia.org/wiki/Complicati ... s_mellitus

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The complications of diabetes mellitus are far less common and less severe in people who have well-controlled blood sugar levels.

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Absolutely not Stephen, the consequences could well be very dire. :wink: :lol:

In situations like these, I like to turn to my old friends at the Cochrane Collaberation. This is what they have to say about the efficacy of ketogenic diet for treating epilepsy:

Our review update included data from four new randomised studies of the ketogenic diet. Although none were blinded, some were of good quality. These studies suggest that in children, the ketogenic diet results in short to medium term benefits in seizure control, the effects of which are comparable to modern antiepileptic drugs. However, one study of long term outcome reports a high attrition rate for the diet. This would suggest that many children find the diet difficult to tolerate. The main reasons for drop-outs in the included studies included gastrointestinal side effects and dislike for the diet.We found just three studies on the use of the diet in adults and none of these were randomised. There has been less research involving other diets. We found one randomised study of reasonable quality of the Atkins diet. This study showed similar benefits in seizure control with a less restrictive diet.For those with medically intractable epilepsy or those in whom surgery is unsuitable, a ketogenic diet could improve seizure control, but tolerability is poor. One observational study suggested that the Atkins diet may have a similar effect on seizure control, but this requires more investigation.

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So some kids couldn't stick it because it doesn't taste so good. Nothing about kidney or liver damage though.

catherinecherub said:

I don't think you can compare ketogenic diets ...

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Catherine I'm just attempting to show that ketogenic diets are accepted as treatments in other medical areas less contentious than the dietary advise given to diet only T2's in the UK. I except the issue was contentious in the past and even accept that people such Stephen Phinney and others can be viewed as contentious but I suggest someone like Eric Kossoff is less so because his area of expertise is not all tied up in diet and diabetes.

As the second link in my post showed it is not just child epilepsy but a whole range of neurological disorders where ketogenic diets are being seen to be an effective treatment and there would be a lot of other non contentious neutral scientists who were doing the research in each of the neurological areas the study shows. On the subject of Eric Kossoff you can actually buy his ketogenic diet for epilepsy book off Amazon but I know to some writing a book will instantly invalidate all his work :lol:

To me advocating a ketogenic diet to a diabetic is just an option that the person may want to consider as I believe they can be effective even though I don't follow a fully ketogenic diet myself. As I said in a later post anyone who adopts a ketogenic diet should ensure they get tests done by their gp but I don't see this as in anyway special or indicating that a ketogenic diet is in anyway significantly more dangerous than adopting any other dietary regime. All diabetics should have their health monitored and if for example being on a ketogenic diet was seen to be a problem then you should assess the size of the problem and decide what to do in a level headed way. No different than if you are on any other dietary regime as T2 which then goes on to show a problem.

As to ketogenic diets leading to death then my response is show me the evidence. Show me a modern scientific study directly relating to ketogenic diets that actually concludes to the effect of the statement you quoted.

The risks of an unsupervised diet can result in malnutrition, chemical imbalance, vitamin deficiency and may even result in death.

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If such as study exists then it would state what that word "risk" actually means when the "unsupervised diet" is a ketogenic one and then I'll be quite happy look at the associated risk in a rational manner in the same way as I assess the risk of my own lchf diet , whether to take a statin or take other medication etc.

catherinecherub said:

The link to the charity, http://www.thedaisygarland.org.uk/epile ... genic-diet is where the words that you have highlighted exist. I am sure if I emailed them they would be able to furnish this as this charity is encouraging ketogenic diets. The cautions would be valid surely? The founders of the charity started this up after losing their daughter to epilepsy. They fund the specialist dietary help needed with the ketogenic diet as the NHS does not pay for this.

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Would they? It's a tiny, tiny charity bringing in less that £50k a year, in all likelyhood run by volunteers (which is brilliant). I run a bigger charity than this in my free time, and nobody checks the copy that I write on my charity website.

When they wrote "ketosis can cause death", I suspect they were confusing it with "ketoacidosis. When they wrote "chemical imbalance" I suspect they were referring to metabolic acidosis, which is a side effect of ketoacidosis. These are honest mistakes,which even some diabetes professionals make, but they're still mistakes.

Potential side effects of a ketogenic diet (from a 2007 American Journal of Clinical Nutrition paper):
http://www.ajcn.org/content/86/2/276.full

As with any large change in nutrient intake, the change to an LCD in patients taking medications for diabetes or hypertension should be made under supervision by clinicians familiar with the effects of the diet. Frequently, a reduction in medication will be required to avoid hypoglycemia and hypotension due to overmedication. In addition, most clinical studies to date have included a daily multivitamin and mineral supplement along with the diet. As mentioned previously, sodium and potassium supplements have also been used.

Only one of the clinical trials has assessed symptomatic side effects of an LCKD (55). In that study, subjects following an LCKD were more likely to experience constipation, headache, muscle cramps, diarrhea, weakness, and skin rash than were those following a low-fat diet. Serious adverse events, such as hospitalization, procedure utilization, or death, were not reported in any of the evaluated studies with enough frequency to allow an assessment of whether the diet may have contributed to those events.

A recent controlled study evaluated a 20-g carbohydrate/d diet for its effects on bone turnover over a 3-mo period (89). In that study, bone turnover markers in subjects who followed the diet did not increase compared with controls at any time. One case report suggested that an LCD contributed to an episode of hypertriglyceridemia-related pancreatitis (90). Another case report raised the possibility that the diet contributed to an episode of mania, perhaps by altering the metabolism of valproic acid (91). Because a large change in dietary intake may alter the availability of vitamins such as vitamin K, the monitoring of patients receiving anticoagulation therapy is important (92, 93). All of these case reports are limited by the difficulty of determining a causal relation.

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In specific regard to ketogenic regimes then my opinion is there is enough good research to show that just like many other dietary regimes they are safe if done correctly. If we extend to accept anecdotal evidence then there are a large number of forum members (both T1 & T2) who have done ketogenic regimes for years and have achieved excellent results. They aren't reporting that they are suffering any complications or are in the process of dying from malnutrition, far from it as many of them have done as well if not better than many of us who don't follow a purely ketogenic regime.

In my opinion what causes defensive reactions are posters who insist their method is the only method that works and to be frank I don't see that it is the members who do ketogenic diets being the ones who are insisting that their method is the only way and should be adopted by everyone.

Again in my opinion there is a very big difference in posting to defend ketogenic diets because others, with very fixed viewpoints, continually post claiming it is dangerous or unsafe as opposed to posting that ketogenic diets are the only way and should be adopted by everyone which would be wrong.

xyzzy said:

In specific regard to ketogenic regimes then my opinion is there is enough good research to show that just like many other dietary regimes they are safe if done correctly. If we extend to accept anecdotal evidence then there are a large number of forum members (both T1 & T2) who have done ketogenic regimes for years and have achieved excellent results. They aren't reporting that they are suffering any complications or are in the process of dying from malnutrition, far from it as many of them have done as well if not better than many of us who don't follow a purely ketogenic regime.

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There are risks associated with a ketogenic diet (or indeed any diet). As with any other way of treating your diabetes, you need to weight up those risks, against the risk of inaction, and the potential risk of diabetic complications.

This is my first law of diabetes:
I prefer to reduce the known risk of DIABETIC complications rather than worry about SPECULATIVE complications of a LCHF/ketogenic diet.

It's working for me so far. My HbA1c is 4.9% and I'm fitter and healthier than I've ever been. The only other diabetics that I know are in the 4% club are ketogenic dieters (with the possible exception of xyzzy, who lives on the edge of ketosis). It's going to take something much stronger than "someone elses doctor", "charity websites" and "blog-posts" to convince me that reducing the risks associated of a ketogenic worth trading for a higher HbA1c.

borofergie said:

with the possible exception of xyzzy, who lives on the edge of ketosis

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Yes that's probably true. When I analyse what I consume it's around 75g a day once I add the semi skimmed milk I put in my tea, coffee and hot chocolate. In term of percentages then its a roughly 15% carbohydrate, 65% fat, 20% protein regime but importantly on average around 95% of the carbs I do eat are coming from vegetables, fruit, yoghurt and milk. I have all but given up starchy and processed carbs except for a round of burgen toast a day and the occasional roast potato with a Sunday roast or tablespoon of pilau rice that I'll have with my Indian takeaway.

I did go fully ketogenic for around 6 weeks a while back mostly to kick start some more weight loss when it stalled and discovered I can make ketostix change to a nice purple colour however on my more normal intake I never show any change of colour but suspect I am existing in some twilight zone. Doesn't bother me at all as all my major risk factors (HbA1c, weight, blood pressure and cholesterol) are normal and I feel fine.

All of this T2 stuff is just a case of minimising risk. Everything anyone does has some risk associated with it but in my opinion the knack is to recognise what the real proven major risk factors are and minimise those however you choose to do it.

Please do not bring other people's posting habits into the discussion.

The discussion of ketosis itself may of course continue

Benedict

Oh darn, it seems that unusually for me, I have missed something. :lol:

Walks away self flagellating before Benedict does it... :wink:

Such an interesting thread...

kokhongw said:

Such an interesting thread...

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Yes on lots of different levels.