The keto diet was the number one searched diet on Google in 2018. Keto pancakes and keto cheesecake were the fourth- and fifth-ranked food search terms.
But as the diet's popularity has increased, so has the controversy surrounding it.
It all begins with very low carbs.
A normal diet consists of about 300 grams of carbohydrates every day, but for people on the keto diet, about 20 grams is the limit. The low-carb intake is replaced with a high consumption of fats. It's similar to the Atkins diet, which was popular in the early 2000s.
When carbohydrates are restricted, the body turns to glycogen, a backup carbohydrate stored in the liver, for energy. When this supply of glycogen is depleted, the liver produces ketones for energy, a process known as ketosis, according to the Mayo Clinic. For people on the keto diet, the goal is to be in a constant state of ketosis, where instead of storing fats the body burns them.
The food pyramid, keto style
Elizabeth Parks, a professor of nutrition and exercise physiology in MU's School of Medicine, said the keto diet is sustainable and the criticism of it is often misguided.
“We know that people can do this forever,” Parks said, referring to a study on the effects of low-carb diets on the heart. "From the metabolism standpoint it is sustainable."
"It’s the social standpoint that can be harder," she said. "You’re removing carbs, the primary food in the American diet.”
Adam Whaley-Connell, professor of medicine in the division of nephrology and hypertension in MU's School of Medicine and associate chief of staff at Truman Veterans' Hospital, said while the short-term gains from a ketogenic diet are great for weight loss, the long-term effects can pose increased risks to the heart and kidneys.
"As a physician, I routinely tell people that these types of high-fat diets can have different implications for your health that may not be in your favor," he said.
For a Boonville woman, Brenda Breland, who has become a social media conduit for people wanting to go keto, there's an irony in the criticism and naysaying she's heard since she became a believer. "No one was worried about me when I ate chips and ice cream for dinner," she said, "but now because I’m doing keto, people think I’m going to die.”
A day in the life
Six months after the birth of her second child, Breland wasn't happy. As a former college volleyball player, she wasn't used to feeling out of shape.
"I just wasn’t in the best place, mentally or physically," she said. "I had a lot of anxiety and didn’t feel like myself."
Breland, who is 29 and works as the membership and marketing director for Columbia Country Club, struggled with the many hormonal and physical changes motherhood can bring. A friend introduced her to a keto drink supplement, and she decided to give it a go, hoping it would help her lose weight and feel healthier. After three months of drinking the supplement and changing to a low-carb diet, she decided to go full keto.
She didn't weigh herself, but she dropped from a size 6 to a size 2 or 1 in the first three months, she said.
Breland begins her day drinking a ketogenic supplement that suppresses her hunger and helps her body stay in ketosis. She only eats between 1 p.m. and 7:30 p.m. For lunch and dinner, she sticks with leafy greens and meats, like a salad and a hamburger without a bun. It all adds up to about 1,400 calories per day, and she's now focusing on gaining muscle.
"After 7:30 at night I only drink water," she said. "I allow myself one treat meal on the weekend, where I’ll maybe consume 80 to 100 grams of carbs instead of the daily 20."
Breland said she has never been in better shape physically or mentally than she is now.
“As a mom, I used to feel totally run-down at the end of the day with a lot of brain fog,” she said. “Now I can keep up with my kids, with my work and everything going on around me.”
Breland works out five days a week for 35 minutes during her lunch hour. Before going on the keto diet, she occasionally exercised and ate an unlimited amount of carbohydrates and sugars.
"I was an athlete so working out wasn't foreign, but I am much stronger and leaner now than I was then," she said.
Low-risk, or high-risk?
Ashley Ritzo, a clinical dietician for MU Health, typically does not recommend the keto diet to her patients trying to lose weight. Her recommendations are based on the sustainability of the diet. "My philosophy on nutrition is to commit only to changes you can do for the rest of your life," she said.
For someone to sustain a ketogenic diet and maintain good health, they must be committed to including plant-based fats like avocados and nuts in their diet, she said.
"One of the problems is that some people end up eating too much of animal-based fats, like bacon," she said.
Whaley-Connell said research shows that high-fat diets in general can have negative health effects in the long-term, regardless of whether the fat comes from plants or animals.
"High-fat diets over time can induce kidney injury both functionally and structurally,” he said. "It does not matter what the source of fat is.”
Cardiovascular risks such as heart disease, stroke and high blood pressure can increase over time with a high-fat diet, he said.
That's why going on the keto diet under the supervision of a physician is important, he said. But he won't recommend it to his patients and explains that the long-term health risks outweigh the short-term weight loss results.
Parks is less persuaded by those risks.
"I wouldn’t say there are no risks, but on the whole the risks are relatively low,” she said. “If you are relatively healthy, it is not a dangerous diet to try. People who are diabetic should check with their doctor before they start the diet. Some diabetes medicines do not work well on the keto diet."
For her patients on low-carb diets, she recommends taking multivitamins, and making sure vitamin C is being replenished. Drinking plenty of water is important, as carbohydrates often supply most of the body's hydration, she said.
“Many people ask what the minimum amount of carbs you need a day is, which is controversial, but it’s important to realize that your liver can supply the body with energy in other ways when on low-carb,” she said.
More than just a diet
Breland posts often about her experience with the keto diet on Facebook and Instagram and has formed multiple challenge groups, a type of online forum, to connect with other people on the diet. She stays in contact with anywhere from 30 to 50 people at a time through social media.
One of those people is Amy Monnig, who Breland met at a previous job. Monnig, who felt she was at an unhealthy weight, was influenced enough by Breland's posts on social media to give the diet a try.
Breland gets emotional when she talks about how much Monnig has changed since she started the diet. "She used to be so quiet and shy, and now she is a whole different person," she said. "It's freaking amazing."
Monnig, 35, joined one of Breland's Facebook challenge groups and began the diet in the fall of 2017. She fully adopted the diet the following January. Since then, she has lost 80 pounds.
"After high school I think I lost track of my identity after going from being with friends all the time to not," she said. "I started dealing with social anxiety. I was depressed and knew I needed a change."
Before going keto, Monnig was not active. Now, she works out at least five days a week and mainly focuses on weight training.
For Monnig, the transition to the keto diet was much easier than she expected, and the quick weight loss helped her stay committed.
"The confidence building has been one of the biggest results," Monnig said. "I have more energy now, and everyday things are easier from being 80 pounds less."
Is it sustainable?
The hardest part of the keto diet for Breland is the negativity and criticism that surrounds the lifestyle.
"The lifestyle isn’t for everyone, but for me, it is sustainable long-term," she said.
Parks, who regularly conducts weight loss studies at the MU School of Medicine, said the quick and large amount of weight loss that results from the keto diet, is explainable in part by three factors:
Losing water weight: Glycogen, the backup carbohydrate in the liver, is stored with water. During ketosis, glycogen becomes depleted and thus water is not being stored.Less sugar means less stored fat: Sugar is a carb, and the carb intake on the ketogenic diet is very low. When fat is consumed with sugar, the body uses the sugar as fuel and stores the fat. When fat is consumed without sugar, the body burns the fat instead.Cutting carbs means cutting calories: When a diet is restricted by something as common as carbohydrates, fewer food options are available to the person. With fewer food choices, people eat less.
For Breland, the lifestyle change came at no additional expense and was an easy transition, even with meals to prepare for two kids and a husband. "When I cook for my family, I just modify it for me," she said. "If my family has tacos, I have a taco bowl.”
Monnig expected grocery shopping to be much harder when she decided to fully adopt the keto diet, but said she gets most of her keto-friendly food from her local Walmart, and finds recipes on Facebook and Pinterest.
Neither woman sees any reason to quit keto.
Breland receives health care from MU and regularly discusses the diet with her physician.
"When I switched to the this lifestyle, I reached out and tried to find a physician who practiced or was an advocate for the diet, and was never able to connect with one," Breland said. "As long as I am practicing a well-formulated ketogenic diet, my physician supports it."
Supervising editor is Katherine Reed.
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