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They are [[Ketogenic Diet as a Treatment| 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.
{{Skeleton}}
=Context=
=Health Risks=
==Death==
There have been two reported cases of sudden death of children on the Ketogenic Diet, probably due to selenium deficiency causing heart failure<ref name="BankShemie2008"/>. Selenium deficiency can occur rapidly; one child was diagnosed with selenium deficiency and related heart problems before their scheduled 3 month selenium test<ref name="Sirikonda-2012"/>. 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<ref name="Best-2000"/>. 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.
==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<ref name="Stenvinkel-1995"/>, increased dopamine excretion<ref name="Swaminathan-1983"/>, or elevated Glucagon<ref name="SaudekBoulter1973"/>. If carbohydrate and sodium intakes are both limited, then the body will secrete the hormone aldosterone<ref name="Phinney-2011-p312"/> which will cause the kidneys to excrete potassium and conserve sodium<ref name="Lote2012"/>. This loss of potassium can cause [[Cramps| Muscle Cramps]] and heart arrhythmias, as well has the loss of [[Muscle| Muscle Tissue]].
==Vitamin or mineral deficiency==
The ketogenic diet is frequently deficient in vitamins and minerals, so supplementation is required with a carbohydrate free multivitamin/mineral<ref name="Kossoff-2011-p137"/>.
* Carnitine may also be required, depending on the results of testing.
* There are case reports of scurvy with the ketogenic diet<ref name="Willmott-2008"/>, so additional supplementation with Vitamin C may be appropriate.
==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.
==Kidney Stones==
5% of the children on the ketogenic diet for epilepsy suffer from kidney stones<ref name="Sampath-2007"/>. A study showed that oral potassium citrate significantly decreased the occurrence of kidney stones<ref name="McNally-2009"/>. It has been shown that while [http://en.wikipedia.org/wiki/Carbonic_anhydrase_inhibitor 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<ref name="Kossoff-2002"/>. (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 [[Health Checks for the Ketogenic Diet| tested for blood]] at least once a week<ref name="Kossoff-2011-p109"/>.
==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<ref name="Kossoff-2011-2452"/>. Generally the ketogenic diet helps stabilize, and normalize blood sugar.
==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<ref name="SolerDixon1972"/>.) Acidosis is not a common problem on the ketogenic diet, but it can occur and symptoms are lethargy, [[Nausea]], vomiting, and headache<ref name="Kossoff-2011-p318"/>. ==Hyperketosis==Excessively high ketone levels can produce symptoms such as rapid panting, irritability, high heart rate, facial flushing, fatigue lethargy, and vomiting<ref name="Kossoff-2011-2680"/>. Taking a couple of tablespoons of orange juice should resolve this, but if a second dose 20 minutes later does not help, seek prompt medical help<ref name="Kossoff-2011-2680"/>.
==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<ref name="Kossoff-2011-2512"/>. Children on the diet for longer than 6 years mostly have normal levels<ref name="Kossoff-2011-2519"/>. 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 Carnitine can be supplemented<ref name="Kossoff-2011-2522"/>.
==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<ref name="Kossoff-2011-p271"/>. 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<ref name="BergqvistSchall2008"/>. However, epilepsy medications are associated with bone loss and calcium metabolism<ref name="Kossoff-2011-p174"/>, so this may also be a contributory factor.
==Growth reduction==
Children treated with the ketogenic diet can have growth reduction<ref name="Kossoff-2011-2533"/>. 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.
==Fatty Liver==
There are case reports of children on the [[MCT Diet]] having fatty infiltration of the liver<ref name="Beverley-1988"/>. It's unclear how common this problem is. (However, a study in rats suggests that MCTs may be a treatment for both non-alcoholic fatty liver disease<ref name="Ronis-2013"Fatty /> and alcoholic fatty liver and medium chain triglyceride (MCT) diet.pdf<ref name="Theuer-1972")/>.
==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.
==Insulin Resistance ==
While the Ketogenic Diet can be beneficial for those suffering from [[Insulin Resistance]] or diabetes<ref name="Veech-2004"/>, there are also concerns that the Ketogenic Diet may also result in some insulin resistance<ref name="Jornayvaz2011"/><ref name="Robinson-1980"/>. There is conflicting evidence for the insulin resistance coming from a low carbohydrate<ref name="KanekoWang1998"/> or a high fat intake<ref name="Anderson-1975"/>. 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. The Ketogenic Diet may also exacerbate reactive hypoglycemia<ref name="Anderson-1975"/>.
==Thirst and Hydration==
Ketones may reduce thirst<ref name="Kossoff-2011-2218"/>.
==Thyroid ==
==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<ref name="Phinney-2011-p343"/>.
==Wound Healing==I've found no studies concerning the effect of the ketogenic diet on wound healing. My personal experience is that wounds heal at a similar rate to a high carbohydrate diet. However, I've experienced far more problems with my skin condition, [[Epidermolysis Bullosa]], with more dystrophic scaring.
=Contraindications=
There are a number of contraindications for the ketogenic diet, including [http://en.wikipedia.org/wiki/Fatty-acid_metabolism_disorder genetic deficiencies in fat metabolism]<ref name="Kossoff-2011-1864"/>. A discussion of these contraindications is outside of the scope of this article.
=See Also=
{{KetoSeeAlso}}
=References=
<references>
<ref name="Sirikonda-2012"> 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 [http://dx.doi.org/10.1007/s00246-012-0219-6 10.1007/s00246-012-0219-6], PMID [http://www.ncbi.nlm.nih.gov/pubmed/22367552 22367552]</ref>
<ref name="BergqvistSchall2008">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 [http://www.worldcat.org/issn/0002-9165 0002-9165], doi [http://dx.doi.org/10.3945/ajcn.2008.26099 10.3945/ajcn.2008.26099]</ref>
<ref name="Robinson-1980"> AM. Robinson, DH. Williamson, Physiological roles of ketone bodies as substrates and signals in mammalian tissues., Physiol Rev, volume 60, issue 1, pages 143-87, Jan 1980, PMID [http://www.ncbi.nlm.nih.gov/pubmed/6986618 6986618]</ref>
<ref name="SolerDixon1972">N.G. Soler, K. Dixon, M.A. Bennett, M.G. Fitzgerald, J.M. Malins, POTASSIUM BALANCE DURING TREATMENT OF DIABETIC KETOACIDOSIS WITH SPECIAL REFERENCE TO THE USE OF BICARBONATE, The Lancet, volume 300, issue 7779, 1972, pages 665–667, ISSN [http://www.worldcat.org/issn/01406736 01406736], doi [http://dx.doi.org/10.1016/S0140-6736(72)92083-1 10.1016/S0140-6736(72)92083-1]</ref>
<ref name="Beverley-1988">D. Beverley, R. Arthur, Fatty liver and medium chain triglyceride (MCT) diet., Arch Dis Child, volume 63, issue 7, pages 840-2, Jul 1988, PMID [http://www.ncbi.nlm.nih.gov/pubmed/3137894 3137894]</ref>
<ref name="Theuer-1972"> RC. Theuer, WH. Martin, TJ. Friday, BL. Zoumas, HP. Sarett, Regression of alcoholic fatty liver in the rat by medium-chain triglycerides., Am J Clin Nutr, volume 25, issue 2, pages 175-81, Feb 1972, PMID [http://www.ncbi.nlm.nih.gov/pubmed/5009783 5009783]</ref>
<ref name="Ronis-2013"> MJ. Ronis, JN. Baumgardner, N. Sharma, J. Vantrease, M. Ferguson, Y. Tong, X. Wu, MA. Cleves, TM. Badger, Medium chain triglycerides dose-dependently prevent liver pathology in a rat model of non-alcoholic fatty liver disease., Exp Biol Med (Maywood), volume 238, issue 2, pages 151-62, Feb 2013, doi [http://dx.doi.org/10.1258/ebm.2012.012303 10.1258/ebm.2012.012303], PMID [http://www.ncbi.nlm.nih.gov/pubmed/23576797 23576797]</ref>
<ref name="Phinney-1983"> SD. Phinney, BR. Bistrian, WJ. Evans, E. Gervino, GL. Blackburn, The human metabolic response to chronic ketosis without caloric restriction: preservation of submaximal exercise capability with reduced carbohydrate oxidation., Metabolism, volume 32, issue 8, pages 769-76, Aug 1983, PMID [http://www.ncbi.nlm.nih.gov/pubmed/6865776 6865776]</ref>
<ref name="Hite-2011"> AH. Hite, VG. Berkowitz, K. Berkowitz, Low-carbohydrate diet review: shifting the paradigm., Nutr Clin Pract, volume 26, issue 3, pages 300-8, Jun 2011, doi [http://dx.doi.org/10.1177/0884533611405791 10.1177/0884533611405791], PMID [http://www.ncbi.nlm.nih.gov/pubmed/21586415 21586415]</ref>
<ref name="Phinney-1980"> SD. Phinney, ES. Horton, EA. Sims, JS. Hanson, E. Danforth, BM. LaGrange, Capacity for moderate exercise in obese subjects after adaptation to a hypocaloric, ketogenic diet., J Clin Invest, volume 66, issue 5, pages 1152-61, Nov 1980, doi [http://dx.doi.org/10.1172/JCI109945 10.1172/JCI109945], PMID [http://www.ncbi.nlm.nih.gov/pubmed/7000826 7000826]</ref>
<ref name="Fery-1982"> F. Fery, P. Bourdoux, J. Christophe, EO. Balasse, Hormonal and metabolic changes induced by an isocaloric isoproteinic ketogenic diet in healthy subjects., Diabete Metab, volume 8, issue 4, pages 299-305, Dec 1982, PMID [http://www.ncbi.nlm.nih.gov/pubmed/6761185 6761185]</ref>
<ref name="Pasquali-1982"> R. Pasquali, M. Parenti, L. Mattioli, M. Capelli, G. Cavazzini, G. Baraldi, G. Sorrenti, G. De Benedettis, P. Biso, Effect of dietary carbohydrates during hypocaloric treatment of obesity on peripheral thyroid hormone metabolism., J Endocrinol Invest, volume 5, issue 1, pages 47-52, PMID [http://www.ncbi.nlm.nih.gov/pubmed/7096916 7096916]</ref>
<ref name="Serog-1982"> P. Serog, M. Apfelbaum, N. Autissier, F. Baigts, L. Brigant, A. Ktorza, Effects of slimming and composition of diets on VO2 and thyroid hormones in healthy subjects., Am J Clin Nutr, volume 35, issue 1, pages 24-35, Jan 1982, PMID [http://www.ncbi.nlm.nih.gov/pubmed/7064875 7064875]</ref>
<ref name="KanekoWang1998">Takashi Kaneko, Pei-Yu Wang, Masato Tawata, Akio Sato, Low carbohydrate intake and oral glucose-tolerance tests, The Lancet, volume 352, issue 9135, 1998, pages 1224, ISSN [http://www.worldcat.org/issn/01406736 01406736], doi [http://dx.doi.org/10.1016/S0140-6736(05)60565-X 10.1016/S0140-6736(05)60565-X]</ref>
<ref name="Anderson-1975"> JW. Anderson, RH. Herman, Effects of carbohydrate restriction on glucose tolerance of normal men and reactive hypoglycemic patients., Am J Clin Nutr, volume 28, issue 7, pages 748-55, Jul 1975, PMID [http://www.ncbi.nlm.nih.gov/pubmed/1146728 1146728]</ref>
<ref name="Kossoff-2011-1864">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 1864</ref>
<ref name="Kossoff-2011-2218">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2218</ref>
<ref name="Kossoff-2011-p271">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 271</ref>
<ref name="Kossoff-2011-2522">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2522</ref>
<ref name="Kossoff-2011-2519">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2519</ref>
<ref name="Kossoff-2011-2512">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2512</ref>
<ref name="Kossoff-2011-2680">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2680</ref>
<ref name="Kossoff-2011-2680">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2680</ref>
<ref name="Kossoff-2011-p318">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 318</ref>
<ref name="Kossoff-2011-2452">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Kindle Offset 2452</ref>
<ref name="Kossoff-2011-p109">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 109</ref>
<ref name="Kossoff-2011-p137">Eric. Kossoff, [http://www.amazon.com/Ketogenic-Diets-Eric-H-Kossoff/dp/1936303108 Ketogenic diets : treatments for epilepsy and other disorders], date 2011, publisher Demos Health, location New York, isbn 1-936303-10-8, Page 137</ref>
