1/16/2020 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS FINDING - PDF document

1/16/2020 COPE WEBINAR SERIES FOR HEALTH PROFESSIONALS FINDING SLIDES FOR TODAY’S WEBINAR January 22, 2020 www.villanova.edu/COPE Ketogenic Diet: R isks, Benefits and Alter natives Click on Shivam Joshi MD webinar description page 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 Nursing Education Continuing Education Programming Research 1 2 OBJECTIVES DID YOU USE YOUR PHONE TO ACCESS THE WEBINAR? 1. Provide an overview of the ketogenic diet, If you are calling in today rather than using your computer to log on, and need including the risks and benefits CE credit, please email cope@villanova.edu and provide your 2. Review the latest evidence on the name so we can send your certificate. 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 Nursing Education Continuing Education Programming Research 3 4 NUTRITION FUTURE FORWARD: CE DETAILS ARE WE READY FOR OUT OF THE BOX THINKING? March 6, 2020 Villanova University College of Nursing is accredited as a 9 AM-4 PM provider of continuing nursing education by the American Driscoll Hall Auditorium Nurses Credentialing Center Commission on Accreditation Villanova University Villanova University College of Nursing Continuing Education/COPE is a Continuing Professional Education (CPE) Accredited Provider with the Commission on RNs: 6 contact hours Dietetic Registration RD/ RDN/ DTR: 6 CPEUs Villanova.edu/cope Nursing Education Continuing Education Programming Research 5 6 1

1/16/2020 CE CREDITS Ketogenic Diet: Risks, Benefits and Alternatives • This webinar awards 1 contact hour for nurses and 1 CPEU for dietitians Shivam Joshi, MD • Suggested CDR Learning Need Codes: Clinical Assistant Professor of Medicine 4000, 5370, 5790, 9020 NYU School of Medicine • Level 2 • CDR Performance Indicators: 6.2.5, 6.3.7, 6.3.8 Nursing Education Continuing Education Programming Research 7 8 DISCLOSURE Ketogenic Diet: The planners and presenter of this program have no conflicts of interest to disclose. Risks, Benefits, and Alternatives Accredited status does not imply endorsement by Villanova Shivam Joshi, MD University, COPE or the American Nurses Credentialing Center of any commercial products or medical/nutrition advice Clinical Assistant Professor displayed in conjunction with an activity. NYU School of Medicine January 22, 2020 9 10 Disclosures Table of Contents • Basics of the Ketogenic Diet • None • Benefits • But, I do eat carbohydrates. • 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 11 12 2

1/16/2020 The Origins of the Ketogenic Diet The Origins of the Ketogenic Diet • Ketones can also be produced by restricting carbohydrates • The ketogenic diet actually first emerged as a treatment for epilepsy • Dr. Wilder then used high-fat, low-carb ketone-inducing diet to produce • Since the time of Hippocrates, people have noticed that fasting similar seizure-reducing effects in pediatric patients with epilepsy suppressed seizure activity • Ketogenic diets for epilepsy were popular until the use of anti-epileptic • Trials of fasting confirmed this in the 1900s drugs (beginning with phenytoin in 1938) • In 1921, Dr. Russell Wilder of the Mayo Clinic thought the benefit • Ketogenic diets later re-emerged in the 20 th century as a treatment for of fasting was actually the ketones produced during fasting obesity and diabetes in the context of the popular low-carbohydrate trend 13 14 How much is 20 to 50 grams The Basics of the Ketogenic Diet of carbs per day? • The ketogenic diet is a very-low Very Low Carbohydrate Diet 20 grams of carbs 50 grams of carbs carbohydrate diet Up to 5 to 10% carbohydrates • 0.8 medium apple OR • 2 medium apples OR • To replace carbohydrates, fat is (20 to 50 grams of carbs per day) • 0.7 medium banana OR • 1.87 medium bananas OR consumed as the primary source of calories • 1.4 slices of whole wheat bread • 3.57 slices of whole wheat bread Low Carbohydrate Diet • Protein is consumed in “moderation” Up to 20% carbohydrates The keto diet is an extreme version of a low-carbohydrate diet 15 16 What are ketones? Keto Diet Ratio • Ketones produced during the Ratio oxidation of fat Acetoacetate - Describes the intensity of the carbohydrate restriction • Keto diet, DKA, alcoholism, starvation (anytime there is a - Example: 4:1 ratio means 4 grams of fat to 1 gram of protein and shortage of usable carbohydrates) carbohydrates combined • Fats are oxidized in the liver to Beta-hydroxybutyrate ketones - Higher the ratio the more intense the carbohydrate restriction • Oxidation of fatty acids yields ATP for energy - Popular ketogenic diets are 4:1 or 3:1 • Ketones are also used for energy Acetone 17 18 3

1/16/2020 What does the keto diet look like? Keto Diet for Weight Loss 19 20 Background on Obesity Low-Fat Foods from Before • Adults obese: 39.8% • Adults overweight or obese: 71.6% • In years past, America’s solution to the obesity epidemic: low-fat diets 21 22 The Problems with Those Low-Fat Diets The Problems with Those Low-Fat Diets Problem 1 Problem 2 Problem 3 • Many foods – although low in fat • These foods simply exchanged • A “low-fat diet” is a diet that is – still were not healthy! calories from fat with calories typically less than 10 to 30% of from refined carbohydrates 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. Serdula et al. AJPH 2004 94(6):2014. 23 24 4

1/16/2020 Low-Fat Diets  Low-Carb Diets The Problems with Those Low-Fat Diets Problem 4 Increasing Caloric Consumption Popular Logic In Reality 1. We never ate healthy foods! • We are eating between 240 to 802 “If restricting fat and eating more more calories per day than we carbs made things worse, then 2. We ate a lot of refined carbs! did ~50 years ago! doing the opposite should fix 3. We never truly were on a low- things.” fat diet! 4. We actually ate more calories! Ford et al. AJCN 97.4 (2013): 848 FAOSTAT Low-carbohydrate diets https://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/ 25 26 Keto Diet for Weight Loss Keto Diet for Weight Loss • Keto enthusiasts tout the diet as • Numerous anecdotal an effective means of weight experiences that are often highly loss publicized • Increased metabolism • Increased satiety However, caloric restriction by • Increased compliance any means will result in weight loss! • Less calories consumed 27 28 Caloric Restriction for Weight Loss: Take 1 Caloric Restriction for Weight Loss: Take 2 • RCT of 160 participants randomly • RCT of 811 overweight assigned to 1 of assigned to either Atkins, Weight 4 diets of different macronutrient Watchers, Zone, or Ornish Diet compositions • No difference in weight loss between • After two years, weight loss was strategies at one year essentially the same on all diets “Amount of weight loss was “CONCLUSIONS associated with self reported Reduced-calorie diets result in clinically dietary adherence level (r=0.60; meaningful weight loss regardless of which macronutrients they emphasize.” P<.001) but not with diet type (r=0.07; P=.40).” 29 30 5

1/16/2020 Caloric Restriction for Weight Loss: Take 3 Caloric Restriction for Weight Loss: Take 4 • RCT of 609 participants • Meta-analysis of 53 studies and assigned to either a LOW-FAT 68,128 people or a LOW-CARBOHYDRATE diet for 12 months • No significant difference in weights between the two groups at 12 months 31 32 But What about Fat Loss and Energy But what about ketogenic diets for weight loss ? Expenditure? • Meta-analysis of randomized • Meta-Analysis of 32 controlled controlled trials lasting for more feeding studies than 12 months • Both energy expenditure and fat • 13 studies involving 1,415 individuals loss are higher on low fat diets • 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? 33 34 Dietary adherence is important for weight loss, but this diet is very hard to adhere to… Some of the Weight Lost is Not Fat…. Fat Free (Lean Body) Mass Loss Water Loss 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 Kirkpatrick et al. Journal of Clinical Lipidology. 2019;13:689,711. 110(7): 1178 35 36 6