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Clinical Dietitian's Two Cents: Ketogenic Diet (Part II)

The ketogenic diet have been claimed to help lose weight, reverse diabetes, reduce blood cholesterol levels, and others. How true are these claims and are there any side effects to be concerned of?


The keto flu is a collection of symptoms experienced when a person starts on a keto diet. The combination and duration of symptoms differ from person to person. Here are some short term side effects of keto flu:

1. Nausea/ dizziness

2. Difficulty sleeping

3. Flu-like symptoms

4. Lethargy & reduced athletic performance

5. Constipation/ Diarrhea

6. Muscle soreness/ cramps

7. Sugar cravings

8. Bad or fruity smelling breath



However, a 10-year study on keto and epilepsy children found on the following long term effects:

  • Constipation (65%)                                 

  • High triglycerides (40%)

  • High cholesterol (29%)

  • Diarrhea (19%)

  • Lethargy (17%)

  • Iron deficiency (15%)

  • Vomiting (13%)



There are some researches on keto and blood lipids:

♦ Systematic review of 12 months follow up on the ketogenic diet vs low fat diet found in the keto group

  • Reductions in triglycerides

  • Increase in LDL-cholesterol and HDL cholesterol


♦ Meta-analysis on low carbohydrate diet (<60g CHO/day) vs low-fat diet found in the low carb group

  • Reductions in triacylglycerides

  • Increase in total cholesterol, LDL-cholesterol and HDL-cholesterol

The unfavourable changes in LDL-cholesterol cautions against the low-carb or keto diet for weight loss and health.


♦ A systematic review on ketogenic diet vs low fat diet reported no significant difference in glucose, insulin and HbA1c at12 months.

♦ Some cross-sectional studies found improved HbA1c, blood glucose levels, and reduction of insulin use in individuals with diabetes on keto or low-carb diets.

Limitations of cross-sectional studies (small sample size, short period of follow up) calls for future studies evaluating long-term outcomes before a keto diet can be endorsed in diabetes management.



Watch Out If You Have Diabetes !!

The risk of hypoglycemia is a major concern as the carbohydrate intake is greatly restricted.


Diabetes Ketoacidosis

Is a life-threatening complication which occurs when ketones build up too quickly in the blood making blood acidic (acidosis). Severe acidosis can cause organ failure, shock and even death. It occurs high risk especially for those individuals with Type 1 Diabetes or taking sulphonylurea medications such as gliclazide (Diamicron), glibenclamide (Daonil), glipizide (Minodiab) and glimepiride (Amaryl).




Watch Out If You Have Gastroesophageal Reflux Disease (GERD) !!

High fat content of the keto diet will worsen GERD symptoms because high fat food requires more time to digest and stays longer in the stomach. It also relaxes the lower esophageal sphincter (LES) and allows stomach acid back up the esophagus causing heartburn.




Watch Out If You Have Kidney Issues and/ or Gout !!

People with chronic kidney disease require a protein restriction to delay progression to kidney failure and this may not align with the keto diet requirements. 

Keto diet increases the risk of kidney stones and gout because the high intake of animal products will increase the acidity of urine, calcium and uric acids levels. This combination makes a person become more susceptible to kidney stones. Ketone bodies limit the reabsorption of uric acid and the subsequent excretion thus increasing the risk of gout attacks.



Other Concerns…

Vitamin and mineral deficiencies may happen due to the reduced intake and lamination of some food like whole grains, fruits and vegetables. Electrolytes such as sodium and potassium may also be deficient. Therefore, supplementations are required such as magnesium, iron, zinc, calcium, B vitamins and vitamin D.


Besides, muscle loss can happen too because this possibly relates to less effective musclbuilfing with protein alone compared to both protein and carbohydrates after exercise.Som small studies suggest that people on the keto diet lose muscle mass even when they continue resistance training. 


In conclusion, there are short term benefits of weight loss, improvement in triglyceride levels and blood sugar levels on a keto diet. However, these effects are not significantly different compared to other conventional weight loss methods. However, the potential side effects are also numerous. I would personally recommend the Mediterranean diet, the DASH diet, or simply the Health Plate model which are proven to be safe and improve health in the long run. If you are still thinking about trying the ketogenic diet, PLEASE consult your doctor and dietitian (yours truly available) regardless of any preexisting health conditions. 



Written by, 

Dietitian Ivy Cheah


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