Foods that can be incorporated in a ketogenic dietary plan.

In 2015, Virta Health and Indiana University Health (IUH) began caring for hundreds of patients with type 2 diabetes (T2D) using a ketogenic diet combined with continuous remote care guided behavior change. We recently published the study 2-year outcomes in Frontiers in Endocrinology showing diabetes reversal in the majority of patients, sharp reductions in medication use and overall metabolic improvement from weight loss to reduction in hypertension. The American Diabetes Association has changed their 2019 standards of care and dietary consensus statement based on our results and other published trials to incorporate individualized carbohydrate restriction including nutritional ketosis for patients with T2D.

Meanwhile, “keto” diets have gone from obscurity to the spotlight in the popular media, garnering not only praise but also criticism from those unfamiliar with the long-established health benefits of ketosis and newly emerging scientific studies into its mechanism of action and clinical implementation. Other commentators are hostile to changes to the medical status-quo and low-fat dietary dogma. A quick internet search can make keto look fad, fringe and downright frightening, but most of the objections are myths that can be debunked by actual data from clinical trials. Our study measured numerous clinical and laboratory outcomes and gathered patient feedback on daily symptoms. *

Here are the top 12 keto myths that we can debunk after providing over 150,000 days of patient care in the Virta-IUH type 2 diabetes reversal clinical trial.

Myth Number 1. Keto is unsustainable. — False. Nearly all T2D intervention patients achieved nutritional ketosis based on daily tracking of blood beta hydroxybutyrate (BHB). BHB was still elevated 50% over baseline at 2 years as carbohydrate restriction was individualized. 74% of patients completed 2 years of the clinical trial with extensive tracking demands and most asked to extend their participation out to 5 years.

Myth Number 2. Keto will cause diabetic ketoacidosis (DKA). — False. There were no DKA events in the trial. There was no evidence of metabolic acidosis or anion gaps in our patients.

Myth Number 3. Keto will cause hypoglycemia or low blood sugar. — False. There were no instances of symptomatic hypoglycemia while patients were in ketosis. **

Myth Number 4. Keto will deprive the brain of required glucose. — False. When dietary carbs are reduced, the liver produces glucose by gluconeogenesis. Blood glucose levels are not low in ketosis and the brain can also metabolize ketones. In our trial, patients’ daily ratings of mood and energy improved. In surveys, patients reported reduced symptoms of depression. In fact, ketosis is used to treat neurologic conditions such as epilepsy and improves cognitive performance.

Myth Number 5. Keto will impair heart function and cause vascular damage. — False. The 10-yr ASCVD risk score of our patients improved 12%. At 1 year, there was no change to CIMT (carotid intima-media thickness) as measured by carotid ultrasound. Significant improvements were observed in 22 of 26 cardiovascular risk factors in the intervention group versus 0 of 26 in the usual care group. In fact, recent studies are investigating the ability of ketosis to improve congestive heart failure. ***

Myth Number 6. Keto will worsen the blood lipid profile. — False. Patients showed improvement in triglycerides and HDL cholesterol. While calculated LDL cholesterol rose, there was no change in the mean number of LDL particles as measured by both NMR lipoprofile and apolipoprotein B. There was a favorable shift of LDL subtype from small dense LDL to large buoyant LDL. (A deep dive on lipid response to ketosis is provided here.)

Myth Number 7. Keto will cause inflammation. — False. Inflammation was sharply reduced including a 35% reduction in high sensitivity C-reactive protein (hsCRP) and a 7% reduction in white blood cell (WBC) count at 2 years. In surveys, patients reported improvement in joint function with reduced pain. This is actually expected as mechanism of action studies show that ketone bodies (BHB) inhibit the NLRP3 inflammasome.

Myth Number 8. Keto will cause hypothyroidism. — False. Mean thyroid hormone (T4) was unchanged. Thyroid stimulating hormone (TSH) actually showed a numeric decrease rather than an increase that would be expected with an under-active thyroid. There were no new cases of symptomatic hypothyroidism. There is no evidence that the thyroid requires dietary carbohydrates.

Myth Number 9. Keto will harm the liver and increase liver fat. — False. Patients’ liver function was greatly improved. An examination of liver markers at 1 year showed a sharp reduction in both non-alcoholic fatty liver disease (NAFLD) by liver fat score (N-LFS) and liver fibrosis by NAFLD fibrosis score (NFS). The score improvements were seen at 2 years as well.

Myth Number 10. Keto will harm the kidneys. — False. Mean estimated Glomerular Filtration Rate (eGFR) improved. There were no cases of worsening kidney function. While uric acid can show a transient increase during ketoadaptation, uric acid levels were unchanged at 1 and 2 years.

Myth Number 11. Keto will cause muscle loss. — False. Average weight loss of trial participants at 2 years was 10% (about 25 pounds). Dual energy x-ray absorptiometry (DEXA) scan demonstrated that most of the weight loss was due to loss of body fat including abdominal fat content. Lean mass reduction was consistent with overall weight reduction. A more detailed study of body composition during weight loss on a low calorie ketogenic diet showed that over 80% of the weight loss is fat mass.

Myth Number 12. Keto will cause loss of bone mineral density — False. DEXA scan demonstrated no change in spine bone mineral density at both 1 and 2 years.

Work with your medical provider on a care plan for metabolic improvement.

In the coming years, we can expect greater adoption of ketogenic diets for the treatment of diabetes and other metabolic diseases. But as “keto” becomes mainstream, we can also expect more scare-tactics. Empower yourself with information. Look for reputable sources including peer-reviewed clinical trial publications. Share what you find with your medical provider as you work together to create an intervention that can result in improved and sustainable metabolic health.

January 2020 update: Want to learn more? Read Forty Keto Myths Debunked by Clinical Trials and view the talk Debunking Common Keto Myths from CrossFit Health.

* All adverse clinical events in both intervention and usual care participants were reported to the trial institutional review board and published in the 1-year and 2-year outcomes papers. There were no events attributed to the intervention.

** We report in the 1-year outcomes paper that 1 patient no longer following dietary changes had a hypoglycemic event due to insulin use beyond the prescribed dose.

*** We report a small number of cardiac events in both the intervention and usual care arm of the trial as would be expected of patients in this age range.

Help improve this blog. Feedback and corrections welcome. (Follow me on Twitter at @JPMcCarter.)