Revision as of 10:30, 7 November 2013

They are many potential benefits to the ketogenic diet, but there are also a number of potentially serious health risks. It appears that most of these health risks can be mitigated with care.

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1 Perspective

All diets have risk;

2 Context

My of the data on KD risks come from KD epilepsy, obesity, starvation.

3 Health Risks

3.1 Death

There have been two reported cases of sudden death of children on the Ketogenic Diet, probably due to selenium deficiency causing heart failure^[1]. Selenium deficiency can occur rapidly; one child was diagnosed with selenium deficiency and related heart problems before their scheduled 3 month selenium test^[2]. In addition, a study of 20 children on the Ketogenic Diet found heart rhythm abnormalities and heart enlargement in 3 (15%, diet duration 13 ± 8.4 months), and one had severe dilated cardiomyopathy^[3]. The effected children has normal selenium levels, but there was a significant correlation was found between the heart rhythm abnormality (QTc) and both bicarbonate and blood ketones, suggesting the level of acidosis or ketosis may be important factors.

3.2 Sodium Loss and Hypotension

Low carbohydrate diets cause of the kidneys to excrete more sodium. This is known as "natriuresis of starvation", and may be due to low insulin^[4], increased dopamine excretion^[5], or elevated Glucagon^[6]. If carbohydrate and sodium intakes are both limited, then the body will secrete the hormone aldosterone^[7] which will cause the kidneys to excrete potassium and conserve sodium^[8]. This loss of potassium can cause muscle cramps and heart arrhythmias, as well has the loss of muscle tissue.

3.3 Vitamin or mineral deficiency

The ketogenic diet is frequently deficient in vitamins and minerals, so supplementation is required with a carbohydrate free multivitamin/mineral^[9].

• Separate supplementation of Calcium and Vitamin D is also recommended.
• Selenium is important to prevent heart problems (see above).
• Carnitine may also be required, depending on the results of testing.
• There are case reports of scurvy with the ketogenic diet^[10], so additional supplementation with Vitamin C may be appropriate.

3.4 Constipation

Constipation is a common issue as the ketogenic diet is generally low in fiber. Even with supplementary fiber, constipation can still be a problem. This may be partly due to changes in the intestinal flora that occur with the ketogenic diet. There are also indications that some non-fiber carbohydrate parses far enough through the digestive tract to supply fuel to bacteria for fermentation.

3.5 Kidney Stones

5% of the children on the ketogenic diet for epilepsy suffer from kidney stones^[11]. A study showed that oral potassium citrate significantly decreased the occurrence of kidney stones^[12]. It has been shown that while carbonic anhydrase inhibitors are also a risk factor for kidney stones, carbonic anhydrase inhibitors while on the ketogenic diet does not further increase the risk^[13]. (Carbonic anhydrase inhibitors are a type of antiepileptic drug.) Maintaining a good level of hydration is important, and Oral citrates may be appropriate. The urine should be tested for blood at least once a week^[14].

3.6 Hypoglycemia

Hypoglycemia (low blood sugar) seems to predominantly a risk if the ketogenic diet is started with a fast, and blood sugar levels should be checked every 6–8 hours during the first few days of the diet. Generally the ketogenic diet helps stabilize, and normalize blood sugar.

3.7 Acidosis

Uncontrolled diabetic patients can suffer from diabetic ketoacidosis, a life-threatening condition where very high levels of ketones are produced. In diabetic ketoacidosis not only are their high levels of ketones, but also their blood glucose is high, and there is often potassium depletion and dehydration (citation required.) Acidosis is not a common problem on the ketogenic diet, but it can occur and symptoms are lethargy, nausea, vomiting, and headache^[15].

3.8 Elevated cholesterol and blood lipid changes

About 30% of children on the ketogenic diet experience elevated cholesterol levels, but this is normally transient, and the levels return to baseline after 6-12 months^[16]. Broader anecdotal evidence suggests that some people's cholesterol improves, while others cholesterol levels degrade. The health implications of cholesterol while on a Ketogenic Diet are unclear. If cholesterol levels are a concern, then the Ketogenic Ratio could be reduced, the percentage of unsaturated fats increased, MCT can be added, or carnitine can be supplemented^[17].

3.9 Bone fractures

Children on the ketogenic diet suffer a higher rate of bone fractures, with 20% of children on the diet for 6+ years having fractures^[18]. Children on the ketogenic diet have poorer bone health, lower vitamin D levels, lower intakes of calcium and vitamin D, and lower Bone Mineral Content^[19]. However, epilepsy medications are associated with bone loss and calcium metabolism^[20], so this may also be a contributory factor.

3.10 Growth reduction

Children treated with the ketogenic diet can have growth reduction^[21]. However, early uses of the ketogenic diet for epilepsy included calorie restriction below the recommended level for the child, as partial starvation was believed to be important for reducing seizures.

3.11 Fatty Liver

There are case reports of children on the MCT Diet having fatty infiltration of the liver. It's unclear how common this problem is. ("Fatty liver and medium chain triglyceride (MCT) diet.pdf").

3.12 Fat Intake Imbalance

When increasing the geometry fat intake, it is easy to get too much Omega-6. They are anecdotal reports that excessive Omega-6 can cause digestive problems, as well as longer-term health issues. The general recommendation is to avoid too much Omega-6, and aim for saturated or monounsaturated fats.

3.13 Insulin Resistance

While the Ketogenic Diet can be beneficial for those suffering from insulin resistance or diabetes^[22], there are also concerns that the Ketogenic Diet may also result in some insulin resistance^[23]. This would not be expected to be an issue while on a Ketogenic Diet, but it may mean that care should be taken when exiting the Ketogenic Diet.

3.14 Thirst and Hydration

Ketones may reduce thirst^[24].

3.15 Thyroid

Investigate further.

3.16 Gout

The ketogenic diet can produce an initial rise in the level of uric acid in the blood and the level of uric acid returns to baseline after 4-6 weeks, but some individuals can develop gout^[25].

4 Contraindications

There are a number of contraindications for the ketogenic diet, including genetic deficiencies in fat metabolism^[26]. A discussion of these contraindications is outside of the scope of this article.

5 References

1. ↑ Ilana M. Bank, Sam D. Shemie, Bernard Rosenblatt, Chantal Bernard, Andrew S. Mackie, Sudden Cardiac Death in Association With the Ketogenic Diet, Pediatric Neurology, volume 39, issue 6, 2008, pages 429–431, ISSN 08878994, doi 10.1016/j.pediatrneurol.2008.08.013
2. ↑ NS. Sirikonda, WD. Patten, JR. Phillips, CJ. Mullett, Ketogenic diet: rapid onset of selenium deficiency-induced cardiac decompensation., Pediatr Cardiol, volume 33, issue 5, pages 834-8, Jun 2012, doi 10.1007/s00246-012-0219-6, PMID 22367552
3. ↑ TH. Best, DN. Franz, DL. Gilbert, DP. Nelson, MR. Epstein, Cardiac complications in pediatric patients on the ketogenic diet., Neurology, volume 54, issue 12, pages 2328-30, Jun 2000, PMID 10881264
4. ↑ P. Stenvinkel, A. Ottosson-Seeberger, A. Alvestrand, J. Bolinder, Effect of insulin on renal sodium handling and renal haemodynamics in insulin-dependent (type 1) diabetes mellitus patients., Acta Diabetol, volume 32, issue 4, pages 230-4, Dec 1995, PMID 8750761
5. ↑ R. Swaminathan, G. Cope, M. Sheltawy, MR. Lee, JK. Wales, Dopamine excretion during natriuresis of starvation., Int J Obes, volume 7, issue 1, pages 31-5, 1983, PMID 6840964
6. ↑ C. D. Saudek, P. R. Boulter, R. A. Arky, The Natriuretic Effect of Glucagon and Its Role in Starvation, Journal of Clinical Endocrinology & Metabolism, volume 36, issue 4, 1973, pages 761–765, ISSN 0021-972X, doi 10.1210/jcem-36-4-761
7. ↑ Phd Stephen D. Phinney MD, Rd Jeff S. Volek Phd, The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-saving Benefits of Carbohydrate Restriction Sustainable and Enjoyable, 2011, publisher Beyond Obesity LLC, isbn 978-0-9834907-0-8, Page 312
8. ↑ Christopher J. Lote http://www.amazon.com/Principles-Renal-Physiology-Christopher-Lote/dp/0792360745 Principles of Renal Physiology], 22 June 2012, Springer, ISBN 978-1-4614-3785-7
9. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 137
10. ↑ NS. Willmott, RA. Bryan, Case report: scurvy in an epileptic child on a ketogenic diet with oral complications., Eur Arch Paediatr Dent, volume 9, issue 3, pages 148-52, Sep 2008, PMID 18793598
11. ↑ A. Sampath, EH. Kossoff, SL. Furth, PL. Pyzik, EP. Vining, Kidney stones and the ketogenic diet: risk factors and prevention., J Child Neurol, volume 22, issue 4, pages 375-8, Apr 2007, doi 10.1177/0883073807301926, PMID 17621514
12. ↑ MA. McNally, PL. Pyzik, JE. Rubenstein, RF. Hamdy, EH. Kossoff, Empiric use of potassium citrate reduces kidney-stone incidence with the ketogenic diet., Pediatrics, volume 124, issue 2, pages e300-4, Aug 2009, doi 10.1542/peds.2009-0217, PMID 19596731
13. ↑ EH. Kossoff, PL. Pyzik, SL. Furth, HD. Hladky, JM. Freeman, EP. Vining, Kidney stones, carbonic anhydrase inhibitors, and the ketogenic diet., Epilepsia, volume 43, issue 10, pages 1168-71, Oct 2002, PMID 12366731
14. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 109
15. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 318
16. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2512
17. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2522
18. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 271
19. ↑ A. C. Bergqvist, J. I Schall, V. A Stallings, B. S Zemel, Progressive bone mineral content loss in children with intractable epilepsy treated with the ketogenic diet, American Journal of Clinical Nutrition, volume 88, issue 6, 2008, pages 1678–1684, ISSN 0002-9165, doi 10.3945/ajcn.2008.26099
20. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 174
21. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2533
22. ↑ RL. Veech, The therapeutic implications of ketone bodies: the effects of ketone bodies in pathological conditions: ketosis, ketogenic diet, redox states, insulin resistance, and mitochondrial metabolism., Prostaglandins Leukot Essent Fatty Acids, volume 70, issue 3, pages 309-19, Mar 2004, doi 10.1016/j.plefa.2003.09.007, PMID 14769489
23. ↑ F. R. Jornayvaz, Fibroblast growth factor 21, ketogenic diets, and insulin resistance, American Journal of Clinical Nutrition, volume 94, issue 3, 2011, pages 955–955, ISSN 0002-9165, doi 10.3945/ajcn.111.019646
24. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2218
25. ↑ Phd Stephen D. Phinney MD, Rd Jeff S. Volek Phd, The Art and Science of Low Carbohydrate Living: An Expert Guide to Making the Life-saving Benefits of Carbohydrate Restriction Sustainable and Enjoyable, 2011, publisher Beyond Obesity LLC, isbn 978-0-9834907-0-8, Page 343
26. ↑ Eric. Kossoff, Ketogenic diets : treatments for epilepsy and other disorders, date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 1864