1/16/2020 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS January 22, 2020 Ketogenic Diet: R isks, Benefits and Alter natives Moderator: Lisa Diewald, MS, RD, LDN Program Manager MacDonald Center for Obesity Prevention and Education M. Louise Fitzpatrick College of Nursing Nursing Education Continuing Education Programming Research 1 FINDING SLIDES FOR TODAY’S WEBINAR www.villanova.edu/COPE Click on Shivam Joshi MD webinar description page Nursing Education Continuing Education Programming Research 2 DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? If you are calling in today rather than using your computer to log on, and need CE credit, please email cope@villanova.edu and provide your name so we can send your certificate. Nursing Education Continuing Education Programming Research 3 1
1/16/2020 OBJECTIVES 1. Provide an overview of the ketogenic diet, including the risks and benefits 2. Review the latest evidence on the effectiveness of the ketogenic diet in treating obesity and type 2 diabetes. 3. Discuss clinical and practical implications and future research directions Nursing Education Continuing Education Programming Research 4 CE DETAILS Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration Nursing Education Continuing Education Programming Research 5 NUTRITION FUTURE FORWARD: ARE WE READY FOR OUT OF THE BOX THINKING? March 6, 2020 9 AM-4 PM Driscoll Hall Auditorium Villanova University RNs: 6 contact hours RD/ RDN/ DTR: 6 CPEUs Villanova.edu/cope 6 2
1/16/2020 CE CREDITS • This webinar awards 1 contact hour for nurses and 1 CPEU for dietitians • Suggested CDR Learning Need Codes: 4000, 5370, 5790, 9020 • Level 2 • CDR Performance Indicators: 6.2.5, 6.3.7, 6.3.8 Nursing Education Continuing Education Programming Research 7 Ketogenic Diet: Risks, Benefits and Alternatives Shivam Joshi, MD Clinical Assistant Professor of Medicine NYU School of Medicine 8 DISCLOSURE The planners and presenter of this program have no conflicts of interest to disclose. Accredited status does not imply endorsement by Villanova University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice displayed in conjunction with an activity. 9 3
1/16/2020 Ketogenic Diet: Risks, Benefits, and Alternatives Shivam Joshi, MD Clinical Assistant Professor NYU School of Medicine January 22, 2020 10 Disclosures • None • But, I do eat carbohydrates. 11 Table of Contents • Basics of the Ketogenic Diet • Benefits • The Ketogenic Diet for Weight Loss • The Ketogenic Diet for Type 2 Diabetes Mellitus • Potential Risks of the Ketogenic Diet • Pediatric Epilepsy Literature • LDL Cholesterol • Kidney Stones • Conclusion 12 4
1/16/2020 The Origins of the Ketogenic Diet • The ketogenic diet actually first emerged as a treatment for epilepsy • Since the time of Hippocrates, people have noticed that fasting suppressed seizure activity • Trials of fasting confirmed this in the 1900s • In 1921, Dr. Russell Wilder of the Mayo Clinic thought the benefit of fasting was actually the ketones produced during fasting 13 The Origins of the Ketogenic Diet • Ketones can also be produced by restricting carbohydrates • Dr. Wilder then used high-fat, low-carb ketone-inducing diet to produce similar seizure-reducing effects in pediatric patients with epilepsy • Ketogenic diets for epilepsy were popular until the use of anti-epileptic drugs (beginning with phenytoin in 1938) • Ketogenic diets later re-emerged in the 20 th century as a treatment for obesity and diabetes in the context of the popular low-carbohydrate trend 14 The Basics of the Ketogenic Diet • The ketogenic diet is a very-low Very Low Carbohydrate Diet carbohydrate diet Up to 5 to 10% carbohydrates • To replace carbohydrates, fat is (20 to 50 grams of carbs per day) consumed as the primary source of calories Low Carbohydrate Diet • Protein is consumed in “moderation” Up to 20% carbohydrates 15 5
1/16/2020 How much is 20 to 50 grams of carbs per day? 20 grams of carbs 50 grams of carbs • 0.8 medium apple OR • 2 medium apples OR • 0.7 medium banana OR • 1.87 medium bananas OR • 1.4 slices of whole wheat bread • 3.57 slices of whole wheat bread The keto diet is an extreme version of a low-carbohydrate diet 16 What are ketones? • Ketones produced during the oxidation of fat Acetoacetate • Keto diet, DKA, alcoholism, starvation (anytime there is a shortage of usable carbohydrates) • Fats are oxidized in the liver to Beta-hydroxybutyrate ketones • Oxidation of fatty acids yields ATP for energy • Ketones are also used for energy Acetone 17 Keto Diet Ratio Ratio - Describes the intensity of the carbohydrate restriction - Example: 4:1 ratio means 4 grams of fat to 1 gram of protein and carbohydrates combined - Higher the ratio the more intense the carbohydrate restriction - Popular ketogenic diets are 4:1 or 3:1 18 6
1/16/2020 What does the keto diet look like? 19 Keto Diet for Weight Loss 20 Background on Obesity • Adults obese: 39.8% • Adults overweight or obese: 71.6% • In years past, America’s solution to the obesity epidemic: low-fat diets 21 7
1/16/2020 Low-Fat Foods from Before 22 The Problems with Those Low-Fat Diets Problem 1 Problem 2 • Many foods – although low in fat • These foods simply exchanged – still were not healthy! calories from fat with calories from refined carbohydrates Serdula et al. AJPH 2004 94(6):2014. 23 The Problems with Those Low-Fat Diets Problem 3 • A “low-fat diet” is a diet that is typically less than 10 to 30% of calories from fat • America never ate less than 30% of calories from fat (we were never truly on a low-fat diet!) Ford et al. AJCN 97.4 (2013): 848. 24 8
1/16/2020 The Problems with Those Low-Fat Diets Problem 4 Increasing Caloric Consumption • We are eating between 240 to 802 more calories per day than we did ~50 years ago! Ford et al. AJCN 97.4 (2013): 848 FAOSTAT https://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/ 25 Low-Fat Diets Low-Carb Diets Popular Logic In Reality 1. We never ate healthy foods! “If restricting fat and eating more carbs made things worse, then 2. We ate a lot of refined carbs! doing the opposite should fix 3. We never truly were on a low- things.” fat diet! 4. We actually ate more calories! Low-carbohydrate diets 26 Keto Diet for Weight Loss • Keto enthusiasts tout the diet as an effective means of weight loss • Increased metabolism • Increased satiety • Increased compliance • Less calories consumed 27 9
1/16/2020 Keto Diet for Weight Loss • Numerous anecdotal experiences that are often highly publicized However, caloric restriction by any means will result in weight loss! 28 Caloric Restriction for Weight Loss: Take 1 • RCT of 160 participants randomly assigned to either Atkins, Weight Watchers, Zone, or Ornish Diet • No difference in weight loss between strategies at one year “Amount of weight loss was associated with self reported dietary adherence level (r=0.60; P<.001) but not with diet type (r=0.07; P=.40).” 29 Caloric Restriction for Weight Loss: Take 2 • RCT of 811 overweight assigned to 1 of 4 diets of different macronutrient compositions • After two years, weight loss was essentially the same on all diets “CONCLUSIONS Reduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize.” 30 10
1/16/2020 Caloric Restriction for Weight Loss: Take 3 • RCT of 609 participants assigned to either a LOW-FAT or a LOW-CARBOHYDRATE diet for 12 months • No significant difference in weights between the two groups at 12 months 31 Caloric Restriction for Weight Loss: Take 4 • Meta-analysis of 53 studies and 68,128 people 32 But What about Fat Loss and Energy Expenditure? • Meta-Analysis of 32 controlled feeding studies • Both energy expenditure and fat loss are higher on low fat diets 33 11
1/16/2020 But what about ketogenic diets for weight loss ? • Meta-analysis of randomized controlled trials lasting for more than 12 months • 13 studies involving 1,415 individuals • Ketogenic diet showed an additional weight loss of 0.91 kg (1.98 lbs) over low-fat diets • Statistically significant but is it clinically significant? 34 Dietary adherence is important for weight loss, but this diet is very hard to adhere to… So much so that nearly every long-term (>12 months) study Bueno et al. Br J N 2013 reporting carb intake at the end was not actually on a keto diet 110(7): 1178 35 Some of the Weight Lost is Not Fat…. Fat Free (Lean Body) Mass Loss Water Loss Kirkpatrick et al. Journal of Clinical Lipidology. 2019;13:689,711. 36 12
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