Objections to the Keto Diet – Part 14- No Long Term Benefits to Weight Loss

This last objection by a dietitian (Dietitians Weigh in on the Low Carb/Ketogenic Diet) actually has some merit but it’s not really all that important since it emphasizes weight loss and not glycemic control.

…though ketogenic diets [sic: short term] were found to produce the greatest weight loss compared to other diets, in the long term there was no difference

This is not really an objection to the ketogenic diet. If it’s more effective short term and no less effective long term then what’s the problem? Most people would love to have a short term loss particularly if it didn’t cause a long term problem.

The issue is compliance and the ketogenic diet is easier to stick with long term since it is more satisfying.


Objections to the Keto Diet – Part 13 – Difference That Makes No Difference

The next dietitian’s objection (Dietitians Weigh in on the Low Carb/Ketogenic Diet) is:

my plans are very low carb and low GI/GL. I think I stay away from ketogenic for long term eating because it is hard to stick to

This objection really stumps me. The plan is very low carb but not ketogenic? The patients can stick with very low carb but found it hard to stick with keto long term?

Not sure what the objection actually is. I answered the hard to comply question already (Objections to the Keto Diet – Part 1 – Lack of Variety).

Fortunately, the question of which diet is better has been answered in  studies (Keto Diet vs Low Glycemic Index Diet). I looked at another study here (Effects of Eating Low Glycemic Index Foods on HbA1C). Here’s a third look at the same subject (Glycemic Index vs Glycemic load (Reprinted from Aug 2016)),

I tend to like the low GI and low GL approach not because it is effective enough but I like it because it gets people aware of the impact of carbohydrates on their blood sugars. They can learn for themselves what food affect their blood sugars and which foods don’t. They can then make smarter choices.

Other GI/GL Issues

Another limit with the GI/GL method is that there’s a significant person to person variability so it may be hard to generalize to a larger population. Short of individual testing of blood glucose it’s hard to know the individual impact. Here’s the study itself (Estimating the reliability of glycemic index values and potential sources of methodological and biological variability. Nirupa R Matthan Lynne M Ausman Huicui Meng Hocine Tighiouart Alice H Lichtenstein. The American Journal of Clinical Nutrition, Volume 104, Issue 4, 1 . October 2016, Pages 1004–1013).

These data indicate that there is substantial variability in individual responses to GI value determinations, demonstrating that it is unlikely to be a good approach to guiding food choices. Additionally, even in healthy individuals, glycemic status significantly contributes to the variability in GI value estimates.

Here I think the particular dietitian just needs to review the current literature. My earlier posts leaned towards low GI/GL because it does segregate food into higher and lower carb foods.


Objections to the Keto Diet – Part 12 – Consistent Carbohydrate Diet is Better

This response by one of the dietitians (Dietitians Weigh in on the Low Carb/Ketogenic Diet) is something I’ve not heard of before (at least by this name). The suggestion is that this alternate diet is better for diabetics. Here’s the comment:

I would consider suggesting the Consistent Carbohydrate Diet.

Here’s the Consistent Carbohydrate Diet (Int J Pediatr Endocrinol. 2009; 2009: 469623. The Origin of the Constant Carbohydrate Diet. Charles Herbert Read, Jr.). I believe this is what the dietitian I visited in the 1990’s was teaching (or something similar). This diet was developed in 1951.

The developer of the diet had “children with insulin-dependent diabetes” as patients and their mothers had trouble figuring out the standard ADA diet for diabetics. It was just too complicated back in 1951.  From the history above:

This prestigious ADA exchange diet was taught in virtually all the diabetic centers in Canada and the United States. Its concept was that any food which contains an equivalent amount (within 3 grams) of carbohydrate, fat, and protein could be substituted for a similar food if they were in the same food group. The groups were Milk, Meat (sometimes divided into high- or low-fat subgroups), Vegetables, Breads, and Fats. For example, if an eight-ounce glass of skim milk was substituted for an eight-ounce glass of whole milk containing 10 grams of fat, where would one find the 2 fat exchanges that were needed.

The implication was that the insulin need was related to the total calories ingested.

The last line is a solid objection. No need to inject for fat.

It made little sense to me that while insulin is necessary to produce fat, it has a negligible role in its catabolism. So why to pay attention to fat in so far as the insulin requirement is concerned?

The author also observed that people tend to eat a consistent amount of protein so that could be held constant day to day. Remember that Type 1 diabetics typically injected for half the grams of protein (as compared to carbohydrates).

This was an astute observation in that in the end it meant that people who inject insulin only need to track carbohydrates. They will be giving variable amounts of Insulin based on carbs and a constant amount (basal amount) based on the protein levels. So this insight was to keep carbs constant day to day.

I concluded that because insulin is required for the metabolism of the dietary carbohydrate, an appropriate diet for diabetes is one in which the carbohydrate content of each of the meals, although different in amounts at breakfast, lunch, and dinner, would be the same from day to day. Variations in the protein and fat content are ignored.

The method in a nutshell is:

Only the carbohydrate is counted, so any food may be included in the diet by referencing a Carbohydrate Guide and staying within 3 grams of the decided amount of carbohydrates at each eating time. This is the Constant Carbohydrate diet.

This all led to increased compliance in Type 1 diabetics.

After she had used this diet for several months, Adams [] noted that although at first the mothers were confused by this seemingly drastic change, they and the patients easily and even happily adapted to this new way of thinking and doing, especially those of different ethnic origins. Her reaction was typical of the responses of each dietitian who subsequently began using the diet.

From that I would conclude that there’s nothing inherently contradictory between a Low Carb diet and a Constant Carbohydrate diet. The Low Carb diet is just less than 20 or 30 grams of carbs a day.

The insights of the author are probably part of my own thought process. Controlling carbs is good. Keeping carbs at low levels is good. Most problems come from large amounts of carbs.


Objections to the Keto Diet – Part 11 – Heart Disease Gets Worse

This issue raised by a dietitian is interesting:

While trying to control blood sugar levels in diabetics through ketogenic diet, one can exacerbate the symptoms of cardiovascular disorders, or may increase the risk of developing it in case of absence.

There are literally hundreds of studies on the keto diet and heart disease that universally show improvements in cardiovascular markers. Yet somehow this dietitian states that keto makes heart disease (CHD) worse?

Where’s the evidence? This argument seems to have come from the vegan site (Low Carb Diets Found to Feed Heart Disease). This site is a vegetarian site run by Dr. Michael Greger (Wikipedia article):

Michael Herschel Greger (born 1972)[2] is an American physician, author, and professional speaker on public health issues, particularly the benefits of a whole foods, plant-based diet and the harms of eating animal products. He is a vegan and the creator of NutritionFacts.org.

Here’s the study that Dr. Greger refers to on his site:

There has only been one study ever done measuring actual blood flow to the heart muscles of people eating low-carb diets. Dr. Richard Fleming, an accomplished nuclear cardiologist, enrolled 26 people into a comprehensive study of the effects of diet on cardiac function using the latest in nuclear imaging technology–so-called SPECT scans, enabling him to actually directly measure the blood flow within the coronary arteries.

He then put them all on a healthy vegetarian diet, and a year later the scans were repeated. By that time, however, ten of the patients had jumped ship onto the low carb bandwagon. At first I bet he was disappointed, but surely soon realized he had an unparalleled research opportunity dropped into his lap. Here he had extensive imaging of ten people before and after following a low carb diet and 16 following a high carb diet.

Continuing with the article:

Those sticking to the vegetarian diet showed a reversal of their heart disease as expected. Their partially clogged arteries literally got cleaned out. They had 20% less atherosclerotic plaque in their arteries at the end of the year than at the beginning. What happened to those who abandoned the treatment diet, and switched over to the low-carb diet? Their condition significantly worsened. 40% to 50% more artery clogging at the end of the year.

This study is also cited by the Physicians Committee for Responsible Medicine (PCRM) another radical vegan group. It is worth noting that this is a single study with a sole author.

Let’s look at the actual study (Angiology. 2000 Oct;51(10):817-26. The effect of high-protein diets on coronary blood flow. Fleming RM)  and see what it says.

It is really important to understand what this study wasn’t. This study wasn’t intended to be a comparison of High Protein vs High carb diets. The people on the diet were instructed to eat 10 calories per pound of body weight with 15% of their calories from protein, 70% from carbohydrates, and 15% from fat. If this is the alternate to low carb then this is a death sentence for diabetics.

Everyone in the study was only instructed on the High carb diet. There was no instruction given on how to do a “High Protein” diet. The ten people who adopted the High Protein plan did so at some time during the following year.

The High Protein diet doesn’t resemble any Low Carb diet I have seen since the people on the diet only lost an average of 1% of body weight. And their cardio markers as well as heart health got worse. I believe that. They were not on effective diet. There are no macro values given for the High Protein dieters.

This study has so many methodological holes in it that it has no real value. But let’s look at the real story behind the “study”:


Here’s where it gets really interesting. The author of the study, Dr. Richard M Fleming, was the head of the “Fleming Heart and Health Institute”. Sounds like something credible right? Turn out Fleming isn’t what he appears (Former Omaha doctor faces possible sanctions for fraud. Lincoln Journal Star Apr 1, 2010).

Author and former Nebraska physician Richard M. Fleming faces possible sanctions to his medical license following convictions for health care fraud and mail fraud. Fleming, formerly of the Fleming Heart and Health Institute in Omaha, lives in Reno, Nev.

A cardiologist who has appeared on national news programs, Fleming also garnered state scrutiny in 2004 following leaks from a medical examiner’s report into the death of Dr. Robert Atkins, founder of the famed Atkins’ Diet. The New York City medical examiner’s office filed a complaint against Fleming after a group with which he was affiliated said Atkins, comatose following a head injury from a fall on the ice, was obese at the time of his death. The examiner’s office then said it erroneously sent Fleming the report.

Fleming is the author of “Stop Inflammation Now!” “The Diet Myth, Keeping Your Heart Forever Young” and “How to Bypass Your Bypass.”

According to complaints filed by Nebraska and Iowa, Fleming was sentenced to five years of probation and six months of electronically monitored home confinement, and he was ordered to pay $107,244 in restitution after pleading guilty in August to one count each of health care fraud and mail fraud.

Fleming admitted that in 2002 he billed Medicare, Medicaid and Blue Cross Blue Shield of Nebraska for falsely represented medical tests.

In 2004, Fleming admitted, he submitted false data after being paid to perform a clinical study on the health benefits of a soy chip food product.

A state licensure hearing regarding his convictions was March 24, said a spokeswoman with the Nebraska Department of Health and Human Services. An order against Fleming’s inactive medical license, if issued, could take as long as six weeks to be announced.

A similar licensure hearing is set in April before the board of medicine in Iowa, where Fleming’s license was active until Feb. 1.

OK. I think I will wait until someone who doesn’t have convictions for fraud produces a study on this subject.

And yet this guy is quotes by the vegans? Wow. More on their authority:

Hardly an independent researcher (The Corruption of Evidence Based Medicine – Killing for Profit).

Actual Studies On the Subject

Here’s a few studies that show cardiovascular risk factors improve:

Objections to the Keto Diet – Part 10 – Carbs are not nutrients

This objection from a dietitian (Dietitians Weigh in on the Low Carb/Ketogenic Diet) is funny since it’s true on one sense but not what the dietitian intends:

Ketogenic diet emphasizes on one macronutrient (Fat) while ignoring the importance of others (carb, protein and natural sources of vitamin & minerals). Thus, leading towards nutritional deficiencies if followed long term.

I’ve already tackled the protein question earlier in this series (Objections to the Keto Diet – Part 7 – Keto is Low Protein).

No one has ever demonstrated that a lack of carbohydrates leads to nutritional deficiencies in the long term. I did look at the long term studies which show no such deficiencies (Objections to the Keto Diet – Part 4 – Long Term Consequences Are Unknown).

But this charge is more serious. It’s not that the consequences are unknown but they that keto will lead to deficiencies. I’ve not seen any studies showing that and I suspect that there is no basis for this charge other than bald faced assertion.

Produce the evidence or retract the charge. Show me what I am missing in my typical keto micronutrients. I publish them here – my last seven days averages. Show me yours, Dietitian. I bet I do better on keto than you do on your diet.

I do put salt in my coffee and don’t log it so my sodium is fine (just in case they care).

Want to see my other macros? OK. Here’s my last 7 day’s averages. What’s missing, dietitians? 30g net of veggies. 222g of fat. 161g of protein. They will probably tell me I am eating too much protein.

Objections to the Keto Diet – Part 9 – Low Blood Sugar

This objection from one Dietitian (Dietitians Weigh in on the Low Carb/Ketogenic Diet) is particularly ironic:

there is the possibility of low blood sugar, or hypoglycemia, from restricting carbs too much

There are people who afraid of low blood sugar but diabetics aren’t at risk for this. However, a diabetic who is on medication will require adjustment in their medications to lower them as their blood sugar goes down on the keto diet. But remember the definition of diabetes is high blood sugars…

Incredible the scare tactics being used here.

Don’t do keto because your high blood sugar won’t be high anymore.

Don’t these dietitians consider the alternatives? In spite of being on 100 units of Insulin and even being relatively lower carb (under 200 grams of carbs a day) I had horrible control of my blood sugar with numbers ranging all over the place.

With low carb/keto my blood sugar is very steady and constant. Plus being keto fuel fired my blood sugar can get even lower and it isn’t a problem. Remember these curves?

Blood sugar drops and stabilizes in the case of starvation. Eating low carb doesn’t drop blood sugar farther than starvation would.

I would suggest that dietitians develop some sense of compassion and put themselves into the shoes of diabetics who don’t have good control of their blood sugar and help them adjust meds over the week or so of induction.


Objections to the Keto Diet – Part 8 – Missing Micronutrients

This next complaint against the keto diet from a dietitian (Dietitians Weigh in on the Low Carb/Ketogenic Diet) has me puzzled:

Carbohydrate foods from unprocessed or minimally processed sources provide essential nutrients, antioxidants, fiber, and help ensure a healthy gut microbiota.

This is what the ketogenic diet is:

Seems like those things fit the bill quite nicely. What is missing?

Here’s my own shopping.

I get plenty of micronutrients. Certainly more than the average non-keto eater and a heck of a lot more than the Standard American Diet (SAD).


Objections to the Keto Diet – Part 7 – Keto is Low Protein

I would say that there is also some truth to this charge from Dietitians (Dietitians Weigh in on the Low Carb/Ketogenic Diet) . There are prominent proponents of the keto diet who do recommend what I consider to be very low levels of protein (Jason Fung, etc).

Remember that Jason Fung is a kidney doctor and his kidney dialysis patients need to be on limited protein to spare their kidney function. This is not a normal issue for most diabetics.

Studies show that the US RDA for protein are too low (Are the Protein RDA Values Enough?).  I’ve written at length on the value of protein for diabetics (High Protein Diets are Good for Type 2 Diabetics).

Keto is not inherently low protein. And a Dietitian could and should recommend higher levels of protein.


The keto community should have a protein summit and let all of the proponents debate this subject. I am convinced that if the facts get out that protein will remain king.

In the meanwhile, Dietitians can recommend ketogenic diets with the caveat that higher levels of protein are generally beneficial for diabetics.  It’s probably even more important that dietitians teach people how to know how many grams of protein that they are getting.


Objections to the Keto Diet – Part 6- Works for Active Population

The next dietitian’s (Dietitians Weigh in on the Low Carb/Ketogenic Diet) point has both a positive and negative aspect.

Have I seen positive outcomes from it? Yes, though mainly with my more active population.

It is said that the rooster crows just before sunrise. But does the crowing of the rooster cause the sun to rise? No.

Equally here, people who do well on the diet tend to be more active. Active before or after? Is active just a sign of engaged and motivated?

Certainly I was not at all active. I was the very definition of sedentary before. But I was motivated. And now I am very active. So it depends on which snapshot of me that someone would see.

How many sedentary people are that way because they are too obese to take a walk? Probably quite a few. How many of them would welcome being active? Probably nearly all of them.

Don’t let the dietitian judge your book by its cover. Tell them you want to be active. You want to play with your kids or grandkids. You want to do more than just die on the couch.


Objections to the Keto Diet – Part 5 – A “Slew of Risks”

This objection from a dietitian (Dietitians Weigh in on the Low Carb/Ketogenic Diet) actually has some truth in it but in the most serious charge is way off base. Here’s the objection as it was written:

…comes with some a slew of risks. These risks can start with symptoms such as headaches, fatigue, fogginess and if left untreated, possible coma and death. There biggest risk is diabetic ketoacidosis which is the result of too many ketones in the blood, a lack of insulin and blood glucose spiking too high. Left untreated, diabetic ketoacidosis can be potentially fatal.

Keto Flu Symptoms

It is true that the diet has various symptoms during the withdrawal from carbs. The symptoms of keto flu are “headaches, fatigue, fogginess” and they can last a couple of days to as much as a week. And they cause many people to tap out. That’s why it is important to help people understand and treat these symptoms.

These symptoms are similar to the withdrawals from any addictive substance. Sugar is no different. That could cause some who is going through them to ask the question why when they stop eating carbs that they go through the symptoms of heroin withdrawal (albeit in a smaller way)?

If carbs are so good then why am I going through these sorts of symptoms? The first reason comes from the switching of fuel sources from glucose (which drops quickly) to ketones which take a few days to kick in.

This can be seen in studies of starvation. The curve on the left is the blood glucose which falls in the first few days and then levels out. The fact is well all feel worse as our blood sugars drop. That is a normal condition. I felt best when my blood sugar was around 300 (normal is around 85) and unless you are testing your blood sugar you don’t know that you are still just fine.

Around day 2, the ketone bodies start to kick. They are your new fuel and it will take a few days for them to reach sufficient levels to meet your needs.

The reason people feel bad when going into keto is that their body was normally accustomed to being fueled by glycogen and that fuel source is limited.


Along with the drop in glycogen comes a very large drop in water weight. For every gram of glycogen your body stores 3-4 grams of water.  Along with this water loss comes a loss of electrolytes.

For me cramps in my legs (calves in particular) as I was falling asleep. This was my signal that I needed to have more magnesium, potassium and sodium.

This is very easy to treat. For most people just eating a small amount of salt will bring immediate relief. For others more electrolyte supplementation may be required. See this for more information (Electrolytes, Water Retention, Low Carb Diets).

Diabetic Ketoacidosis

This is a rare condition which is not a by-product of the ketogenic diet. Quite the contrary since it is a risk of untreated diabetes. And yes, it is often fatal. I have a personal friend who died from this. It is typically found in someone who is an undiagnosed diabetic.

It is accompanied by very high blood sugars. Remember what happens when you start a ketogenic diet (see above)? Your blood sugar drops. That is why diabetic ketoacidosis is describing a completely different condition. In the untreated diabetic both ketones and high blood sugar are present. In the ketogenic diet ketone levels don’t reach these deadly levels so both conditions for DKA are not present.

The diabetic who doesn’t do a ketogenic diet has a much higher chance of dying from DKA than a diabetic on the ketogenic diet. Again, just comparing the risks shows the dietitian’s claim is false.