Abstract:

The recent rise in popularity of the ketogenic diet raises questions about the efficacy and safety of the practice, and subsequently if it has value in either a clinical setting or in the general public. Despite public perception, the ketogenic diet is just another variation of the low-carbohydrate diet trend. Clinical research shows that while many patients experience dramatic early weight-loss, the effect is temporary and can even contribute to the patient ultimately loses the ability to lose weight in the long-term if they continue. Even in clinical settings under the supervision of dieticians and other medical staff, there is a high degree of non-compliance with the diet, suggesting it is not as easy to maintain as some claim. More concerning is the potential for liver and heart disease indicated in some studies, suggesting that the risks must be carefully managed and medically supervised, and that the use of the diet for average people seeking a weight-loss solution is  risky and ineffective.

The ketogenic diet has become a major dieting trend in Canada in the past decade, with celebrity endorsements and huge attention in both conventional and new media. This paper will provide a brief overview of what is known, what is unknown, and how the diet is portrayed in popular media in Canada. The glamorous, heavily romanticized vision of the ketogenic diet portrayed by media undermines its value as a tool to be employed by patients under direct medical supervision, instead giving the public the impression that it is appropriate to adopt the ketogenic diet without consulting their medical professional. Some studies provide encouraging evidence it can be used to treat chronic pain, depression, and anxiety, while others offer conflicting results regarding the effectiveness of the diet to treat obesity and type 2 diabetes. Other risk factors may include an overall increased risk of cancer, poor long-term cardiovascular outcomes, and potentially greater risk of developing fatty-liver disease. These risks and benefits are not discussed typically in popular media portrayals of the diet, and instead present a silver-bullet solution for long-term weight loss for which the long-term evidence is conflicting at best. Additionally, the portrayal of the diet in some media outlets skirts around the matter of how patients are to ensure the proper intake of micronutrients that are normally accessed through carbohydrate-rich fruits and vegetables; for many people it is not reasonable to assume they would be able to maintain an otherwise properly-balanced diet without medical supervision.

A proper diet is one which is carefully balanced to ensure a person is getting not just all the nutrients they need, but in the correct proportions as well. Managing weight is a major area of concern for Canadians as the obesity rate has consistently climbed for several decades (Hales & Lauzon, 2015). There is a simple truth about weight management that many people simply do not want to hear: there are no miracle cures or shortcuts. Weight gain under normal circumstances is related to an imbalance between caloric intake and physical activity. If, for example, there is excess glucose present in the blood stream, the body detects that imbalance and releases insulin to convert the glucose into fat which is stored for later use (Hales & Lauzon, 2015). It is understandable, therefore, that the average Canadian is interested in reading about diet trends that promise dramatic results with relatively low effort. Weight loss by means of balancing diet and physical activity is safe and healthy, but it is also time consuming and difficult. This creates a media environment where publishers recognize consumer appetite for content focused on fad diets which are frequently ineffective long-term, and potentially unsafe. The 2017 Globe and Mail article from Corey Mintz “The lean, mean ketogenic diet machine” is one such article that glamourizes a fad diet while downplaying the lack of long-term study, and does very little to caution readers against the potential health risks associated with such a dramatic adjustment to the person’s nutrition balance.

Mintz (2017) spends the majority of the article describing the dietary choices of a variety of ketogenic diet adherents, several of whom claim to be long-term participants who are not using the diet as a means of weight management but who intend to adopt it as a long-term lifestyle instead. He describes their weight-loss results at length and devotes considerable time to describing the novel practices allowed by the diet including eating lots of bacon and putting butter in coffee. The article does give a reasonably complete history of the diet. It also very briefly discusses some of the unpleasant side affects associated with the early stages of the ketogenic diet that are referred to as “keto flu”. When discussing keto flu the article references the experience of Dan McKinnon, and quickly pivots from his difficulty with the symptoms to how much his life has changed and how much happier McKinnon claims to be (Mintz, 2017). This appears to be a pattern with this article, to downplay the negative aspects of the diet and the risk factors, while emphasizing the enthusiasm of its promoters. While Mintz does not explicitly endorse the keto diet, it is telling that the only people interviewed for the article have a positive or neutral view of it. Even the nutritionist interviewed is a keto participant who enthusiastically endorses the practice.

In terms of positive influence, Mintz (2017) also dedicates considerable time to discussing the marketability of nutrition supplements to the ketogenic diet crowd. There is considerable discussion on the topic of how popular supplements have become, while casting significant doubt on the efficacy of these supplements to boost the effects of the diet. He also casts doubt on some companies selling keto supplements, highlighting their structure as multi-level marketing companies; this designation is a red flag for many consumers, and is often used interchangeably with the term pyramid scheme.

The effect this article can reasonably be seen to have is to entice anyone who is interested in losing weight to adopt the ketogenic diet, without discussing the short-term or long-term health risks associated with eliminating carbohydrates, one of the three main energy groups used in a normal human diet (Hales & Lauzon, 2015). There are reasonable concerns associated with adopting a high-fat, high-protein diet that is exclusive of carbohydrates. Since much of the fibre and vitamin content essential to a healthy, long-term diet are contained in fruits and vegetables that are also high in carbohydrates, careful balancing of nutrient intake is necessary to maintain the appropriate levels of vitamins and fibre that would usually come with those carbohydrates.

For the average Canadian looking to lose weight, the ketogenic diet is inadvisable because of its dramatic nature of the dietary restrictions it places on participants, resulting in difficulty maintaining certain micronutrients typically accessed through high-carbohydrate fruits and vegetables. There are also long-term health risks, many of which can trigger future weight-gain, associated with the diet that require medical supervision to properly balance. As a tool for medical professionals, there may be value in the ketogenic diet for some extreme cases.

Cardiovascular disease is a major public health concern in Canada, costing the public healthcare system around $22 billion each year (Public Health Agency of Canada, 2012). Obesity and type 2 diabetes are significant risk factors for cardiovascular disease, so the pursuit of weight loss with a ketogenic diet could potentially be viewed as a means of reducing public health expenditure on cardiovascular disease. Evidence from Batch et al (2020) and Kosinski & Jornayvaz (2017) conclude that while the ketogenic diet does show short-term improvement in markers for obesity and type 2 diabetes, however the results do not last in either human or animal subjects in long-term analysis. Furthermore, the associated increases observed in LDL-C and very-low-density lipoproteins are markers for increased cardiovascular risk (Batch et al, 2020). Kosinski & Jornayvaz (2017) also note that being rich in fats, the ketogenic diet may create negative cardiovascular effects. Breukelman et al. (2019) note that a low-carbohydrate, high-fat diet is not an effective tool for managing type-2 diabetes regardless of whether it is used in concert with physical activity. This may suggest the ketogenic diet is an ineffective treatment option overall for those with type-2 diabetes. Another study assessing the results of 9 smaller studies found that diets similar to the ketogenic diet in a clinical setting were effective at managing glycemic control, weight-loss, and blood lipids biomarkers in patients with type-2 diabetes (Bawazir et al., 2021), however the 9 studies analyzed included some timelines as short as three months. Bawazir et al. (2021) give some hope that in a clinical setting the ketogenic diet may have some merit, but it requires significant medical supervision to be successful. In further research, Ross et al. (2021) found that there was improvement in blood pressure and weight for obese diabetic patients, although in all eight studies analyzed they noted low long-term compliance rates. Despite support from physicians, nurses, and dieticians, study participants had difficulty maintaining their diet. A study conducted by the Japan Public Health Center found that due to the increased relative consumption of animal fats and proteins in the ketogenic diet, there was an increase in the risk of cancer to patients (Cai, et al., 2021). All the studies noted here called for larger long-term studies to verify their results, which is a reflection on the recent nature of this research.

One unusual study found that the ketogenic diet may be useful in the treatment of chronic pain by reducing inflammation and improving mental health (Field, et al., 2021). An interesting study that compared a control group against two other groups, adhering to the ketogenic diet and the whole-food diet that restricts processed foods. In this study the group found the ketogenic diet to be most effective at reducing chronic pain, with encouraging results also coming from the whole-food approach (Field, et al., 2021).

There were other negative health effects observed in rodents on the ketogenic diet as well. Non-alcoholic fatty liver disease (NAFLD) was observed (Kosinski & Joynayvaz, 2017). Studies involving human subjects and inflammation of the liver in relation to the ketogenic diet are not yet available, but if this issue were also to present in human patients it would be a significant risk factor. Liver disease is treatable but a serious health risk that may prove to be associated with the ketogenic diet. Notably, NAFLD is also a contributor to long-term obesity and cardiovascular disease (Kosinski & Joynayvaz, 2017). Additionally, the Kosinski & Joynayvaz (2017) study found that subsequent to NAFLD, rodents also developed insulin resistance. This is a disorder associated with type 2 diabetes, obesity, and heart disease.

From a public health perspective if the intention is to reduce the $22 billion annual cost of cardiovascular disease (PHAC, 2012) by reducing obesity, the ketogenic diet offers short-term results with high potential for long-term counterproductive effects. The Mintz (2017) article presents the anecdotal accounts of a variety of people with connections to the diet, and offers what appears to be a glamourous view of a ketogenic lifestyle. Unfortunately, the article de-emphasizes what little is currently understood about the risks, and barely mentions the overall lack of study of the ketogenic diet. Despite not explicitly endorsing the ketogenic diet, the tone and choice of sources of this article represents tacit endorsement, and creates buzz and attention for potentially risky behaviour.

To conclude, Mintz’s 2017 Globe and Mail article discussing the ketogenic diet is a mixed bag of bad health advice and a healthy dose of nutrition supplement skepticism. While Mintz goes to great lengths to glamourize the diet and essentially promote it as not only a good weight-loss solution, but perhaps even as a solid long-term lifestyle, he downplays the risk factors and virtually ignores the limited long-term research available. The enthusiastic support offered by nearly all interview subjects suggests the ketogenic diet to be not just a fast and relatively easy weight-loss solution, but also safe. Moreover, the author highlights the novelty of a restrictive diet that allows participants to eat all the cheese, butter, and bacon they want without consequence, despite the well-established health risks of those foods including high cholesterol, cancer, and cardiovascular disease (Hales & Lauzon, 2015). This approach is irresponsible, offering readers an obscured image of the realities of this fad diet and its long-term implications. Contrary to the content of Mintz’s article, current research shows that the ketogenic diet is a poor method of weight loss and that most human subjects regain their lost weight within 12 months (Batch, et al, 2020, and Kosinski & Jornayvaz, 2017). Moreover, participants may be predisposed to cardiovascular disease due to high cholesterol related to the high fat content of the diet, or further weight gain related to insulin resistance and/or NAFLD (Batch, et al, 2020, and Kosinski & Jornayvaz, 2017).  There is not much good research currently available to conclusively say how likely the ketogenic diet is to trigger these issues, but there is certainly enough to give pause to anyone considering trying this approach to weight management, particularly without the advice of a doctor.