Category Archives: Ketogenic Mediterranean Diet

Are Low-Carb Diets More Effective Than Others?

DietDoctor Andreas Eenfeldt has a list of 16 scientific studies suggesting the superiority of low-carb diets for weight loss. I hope he keeps updating it. Here it is.

For my version of a low-carb diet, see KMD: Ketogenic Mediterranean Diet or Advanced Mediterranean Diet (2nd Ed.). The latter book also has a traditional “balanced” calorie-controlled diet with greater variety than a very low-carb diet. Ketogenic diets are getting a boost recently from Dr. Georgia Ede, Dr. Peter Attia, and the Livin’ La Vida Low-Carb Man, Jimmy Moore.

Steve Parker, M.D.

Too Much Mouse and Molecular Biochemistry!

That’s my primary assessment of an article I read in Current Opinion on Clinical Nutrition and Metabolic Care.  The title is “Low-carbohydrate ketogenic diets, glucose homeostasis, and nonalcoholic fatty liver disease.”

Don't assume mouse physiology is the same as human's

Don’t assume mouse physiology is the same as human’s

The article’s more about mice than my patients.

The authors share some stats about nonalcoholic fatty liver disease (NAFLD):

  • the earliest stage is fat build-up in the liver
  • 15% of the nonobese population has NAFLD
  • 65% of the obese have NAFLD
  • it can progress to an inflammatory disorder (nonalcoholic steatohepatitis (NASH)
  • about two out of 10 NASH patients progress to cirrhosis within 10 years
  • NAFLD is an independent predictor of heart and vascular disease, an even stronger predictor than overall body fat mass (even visceral fat)
  • insulin resistance is strongly linked to NAFLD

The Washington University School of Medicine authors say good things about low-carbohydrate ketogenic diets for weight loss and seizure control.  They spend the rest of the article talking about rodent physiology and lab chows—right up Carbsane Evelyn‘s alley.  But not mine.  Bores me to tears.

They do mention the small Browning study that showed a very-low-carb ketogenic diet superior to a calorie-restricted diet for reducing liver fat in humans. Weight loss by various methods is a standard recommendation for humans with NAFLD; I wouldn’t be surprised multiple different diets worked.  It may be the weight loss, not the diet, that does the trick.  We have just one human study thus far indicating a ketogenic diet is more effective short-term.

Here’s the full Browning study if you care to read it yourself.

If I were obese and had NAFLD, I’d go on a very-low-carb ketogenic diet (like this one).

Steve Parker, M.D.

Reference:  Schugar, Rebecca, and Crawford, Peter.  Low-carbohydrate ketogenic diets, glucose homeostasis, and nonalcoholic fatty liver disease.  Curr Opin Clin Nutr Metab Care, 2012, vol. 15.  doi: 10.1097/MCO.0b013e3283547157

Dietitian Franziska Spritzler’s Six-Month Ketogenic Diet Trial Results

Steve Parker MD, Advanced Mediterranean Diet

Two diet books in one: 1) portion control, and 2) ketogenic

Ketogenic diets help many folks lose excess weight, return blood sugar levels toward normal, and move HDL cholesterol and triglycerides to a healthier range. I include a ketogenic diet as an option in my Advanced Mediterranean Diet (2nd Ed.). They are not for everybody.

Read about Franziska Spritzler’s experience with a ketogenic diet (not my version). Some quotes:

Well, after consistently consuming 30-45 grams of net carbs a day for six months, I have only positive things to say about my very-low-carb experience. Not only are my blood sugar readings exactly where they should be — less than 90 fasting and less than 130 an hour after eating — but I truly feel healthier,  less stressed, and more balanced than ever.

My diet consists of lots of fat from avocados, nuts and nut butters, olive oil, and cheese; moderate amounts of fish, chicken, beef, Greek yogurt, and eggs; and at least one serving of nonstarchy vegetables at every meal and a small serving of berries at breakfast.  It’s truly a rich, satisfying, and luxurious way to eat.

Does Diet Affect Age-Related Memory Loss and Dementia Risk?

dementia, memory loss, Mediterranean diet, low-carb diet, glycemic index, dementia memory loss

Don’t wait to take action until it’s too late

High blood insulin levels and insulin resistance promote age-related degeneration of the brain, leading to memory loss and dementia according to Robert Krikorian, Ph.D.  He’s a professor in the Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati Academic Health Center.  He has an article in a recent issue of Current Psychiatry – Online.

Proper insulin signaling in the brain is important for healthy functioning of our brains’ memory centers.  This signaling breaks down in the setting of insulin resistance and the associated high insulin levels.  Dr. Krikorian makes much of the fact that high insulin levels and insulin resistance are closely tied to obesity.  He writes that:

Waist circumference of ≥100 cm (39 inches) is a sensitive, specific, and independent predictor of hyperinsulinemia for men and women and a stronger predictor than body mass index, waist-to-hip ratio, and other measures of body fat.

Take-Home Points

Dr. Krikorian thinks that dietary approaches to the prevention of dementia are effective yet underutilized.  He mentions reduction of insulin levels by restricting calories or a ketogenic diet: they’ve been linked with improved memory in middle-aged and older adults.

Dr. K suggests the following measures to prevent dementia and memory loss:

  • eliminate high-glycemic foods like processed carbohydrates and sweets
  • replace high-glycemic foods with fruits and vegetables (the higher polyphenol intake may help by itself)
  • certain polyphenols, such as those found in berries, may be particularly helpful in improving brain metabolic function
  • keep your waist size under 39 inches, or aim for that if you’re overweight

I must mention that many, perhaps most, dementia experts are not as confident  as Dr. Krikorian that these dietary changes are effective.  I think they are, to a degree.

The Mediterranean diet is high in fruits and vegetables and relatively low-glycemic.  It’s usually mentioned by experts as the diet that may prevent dementia and slow its progression.

Read the full article.

I’ve written before about how blood sugars in the upper normal range are linked to brain degeneration.  Dr. Krikorian’s recommendations would tend to keep blood sugar levels in the lower end of the normal range.

Steve Parker, M.D.

PS: Speaking of dementia and ketogenic, have you ever heard of the Ketogenic Mediterranean Diet?  (Free condensed version here.)

What Do Dietitians Think About Ketogenic Diets?

You get it?

Registered Dietitian Franziska Spritzler recently reviewed the concept of low-carb ketogenic diets.  She thinks they are a valid approach to certain clinical situations.  Among dietitians, this puts her in a small but growing minority.

One of your weight-loss choices in my Advanced Mediterranean Diet (2nd Edition) is a ketogenic diet.  Here’s the basic program.

I hesitate to mention this, but I will anyway.  Many, if not most, dietitians too easily just go along with the standard party line on low-carb eating: it’s rarely necessary and quite possibly unhealthy.  Going along is much easier than doing independent literature review and analysis.  I see the same mindset among physicians.

Franziska breaks the mold.

Steve Parker, M.D.

Spanish Ketogenic Mediterranean Diet

Ever heard of the Spanish Ketogenic Mediterranean Diet? It looks like a low-carb quasi-Mediterranean diet.

Researchers with the University of Cordoba in Spain studied 40 subjects eating a low-carb “Mediterranean” diet for 12 weeks. The results were strikingly positive.

Methodology

A medical weight loss clinic was the source of 40 overweight subjects, 22 males and 19 females, average age 38, average body mass index 36.5, average weight 108.6 kg (239 lb). These folks were interested in losing weight, and were not paid to participate.

Nine subjects were not included in the final analysis due to poor compliance with the study protocol (3), the diet was too expensive (1), a traumatic car wreck (1), or were simply lost to follow-up (4). So all the data are pooled from the 31 subjects who completed the study.

Blood from all subjects was drawn just before the study began and again after 12 weeks of the diet.

Study diet: Low-carbohydrate, high in protein [and probably fat, too], unlimited in calories. Olive oil was the main source of fat (at least 30 ml daily). Maximum of 30 grams of carbohydrates daily as green vegetables and salad. 200-400 ml daily of red wine. The authors write:

Participants were permitted 3 portions (200 g/portion) of vegetables daily: 2 portions of salad vegetables (such as alfalfa sprouts, lettuce, escarole, endive, mushrooms, radicchio, radishes, parsley, peppers, chicory, spinach, cucumber, chard and celery), and 1 portion of low-carbohydrate vegetables (such as broccoli, cauliflower, cabbage, artichoke, eggplant, squash, tomato and onion). 3 portions of salad vegetables were allowed only if the portion of low-carbohydrate vegetables were not consumed. Salad dressing allowed were: garlic, olive oil, vinegar, lemon juice, salt, herbs and spices.

The minimum 30 ml of olive oil were distributed unless in 10 ml per principal meal (breakfast, lunch and dinner). Red wine (200–400 ml a day) was distributed in 100–200 ml per lunch and dinner. The protein block was divided in “fish block” and “no fish block”. The “fish block” included all the types of fish except larger, longer-living predators (swordfish and shark). The “no fish block” included meat, fowl, eggs, shellfish and cheese. Both protein blocks were not mixed in the same day and were consumed individually during its day on the condition that at least 4 days of the week were for the “fish block”.

Trans fats (margarines and their derivatives) and processed meats with added sugar were not allowed.

Vitamin and mineral supplements were given.

Subjects measured their ketosis state every morning with urine ketone strips.

Results (averaged)

  • Body weight fell from 108.6 kg (239 lb) to 94.5 kg (209 lb), or 2.5 pounds per week
  • Body mass index fell from 36.5 to 31.8
  • Systolic blood pressure fell from126 to 109 mmHg
  • Diastolic blood pressure fell from 85 to 75 mmHg
  • Total cholesterol fell from 208 to 187 mg/dl
  • LDL chol fell from 115 to 106 mg/dl
  • HDL chol rose from 50 to 55 mg/dl
  • Fasting glucose dropped from 110 to 93 mg/dl
  • Triglycerides fell from 219 to 114 mg/dl
  • No significant differences in male and female subjects
  • No adverse reactions are mentioned

Researchers’ Conclusions

The SKMD [Spanish Ketogenic Mediterranean Diet] is safe, an effective way of losing weight, promoting non-atherogenic lipid profiles, lowering blood pressure and improving fasting blood glucose levels. Future research should include a larger sample size, a longer term use and a comparison with other ketogenic diets.

My Comments

The researchers called this diet “Mediterranean” based on olive oil, red wine, fish, and vegetables.

What’s “Not Mediterranean” is the paucity of carbohydrates (including whole grains); lack of yogurt, nuts, and legumes; and the high meat/protein intake.

The emphasis on olive oil, red wine, and fish could make this healthier than other ketogenic diets.

Ketogenic diets are notorious for high drop-out rates compared to other diets. But several studies suggest greater short-term weight loss for people who stick with it. Efficacy and superiority are little different from other diets as measured at one year out.

Many of the metabolic improvements seen here might be duplicated with loss of 30 pounds (13.6 kg) over 12 weeks using any reasonable diet.

Average fasting blood sugars in these subjects was 109 mg/dl. Although not mentioned by the authors, this is in the prediabetes range. The diet reduced average fasting blood sugar to 93, which would mean resolution of prediabetes. Dropping body mass index from 36 to 32 by any method would tend to cure prediabetes.

Elevated blood sugar is one component of the “metabolic syndrome.” Metabolic syndrome was recently shown to be reversible with a Mediterranean diet supplemented with nuts.

If you’re thinking about doing something like this, get more information and be sure to get your doctor’s approval first.

My Ketogenic Mediterranean Diet has much in common with the study at hand. One of several major differences is that it’s user-friendly and ready to implement as soon as you have your physician’s clearance. It’s posted at the Diabetic Mediterranean Diet Blog.

Steve Parker, M.D.

Addendum:

In April, 2008, had a delightful conversation with Jimmy Moore, of Livin’ La Vida Low-Carb fame regarding this study. I reviewed this article in preparation.  It struck me that the Spanish Ketogenic Mediterranean Diet is probably higher in protein and lower in fat than many other ketogenic weight-loss diets. Since fish is emphasized over other animal-derived foods, it’s likely also lower in saturated fat. (In low-carb diets, carbohydrates are substituted with either fats or proteins.)

References and Additional Reading:

Perez-Guisado, J., Munoz-Serrano, A., and Alonso-Moraga, A. Spanish Ketogenic Mediterranean diet: a healthy cardiovascular diet for weight loss. Nutrition Journal, 2008, 7:30. doi:10.1186/1475-2891-7-30 I like the idea behind Nutrition Journal. From the publisher’s website:

Nutrition Journal aims to encourage scientists and physicians of all fields to publish results that challenge current models, tenets or dogmas. The journal invites scientists and physicians to submit work that illustrates how commonly used methods and techniques are unsuitable for studying a particular phenomenon. Nutrition Journal strongly promotes and invites the publication of clinical trials that fall short of demonstrating an improvement over current treatments. The aim of the journal is to provide scientists and physicians with responsible and balanced information in order to improve experimental designs and clinical decisions.

With the advent of the Internet, has dawned a new way to exchange information and to publish biomedical journals. BioMed Central has been a pioneer in online publishing with Nutrition Journal being one of its many journals. Publication in Nutrition Journal offers many advantages over traditional paper publications; the journal offers free access to its articles; high quality and rapid peer-review; immediate publication; and most importantly, universal access to its content from virtually any place in the world.

Bravata, D.M., et al. Efficacy and safety of low-carbohydrate diets: a systematic review. Journal of the American Medical Association, 289 (2003): 1,837-1,850.

Gardner, C.D., et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women: the A TO Z Weight Loss Study: a randomized trial. Journal of the American Medical Association, 297 (2007): 696-677.

Stern, L., et al. The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Annals of Internal Medicine, 140 (2004): 778-785.

Shai, Iris, et al. Weight Loss with a Low-Carbohydrate, Mediterranean, or Low-Fat Diet. New England Journal of Medicine, 359 (2008): 229-241.

Is a Low-Carb Diet Safe for Obese Adolescents?

I answered this question last year at the Diabetic Mediterranean Diet Blog, based on research from the Department of Pediatrics, University of Colorado.

It’s an important question. Childhood obesity in the U.S. tripled from the early 1980s to 2000, ending with a 17% obesity rate. Overweight and obesity together describe 32% of U.S. children. Some experts believe this generation of kids will be the first in U.S. history to suffer a decline in life expectancy, related to obesity.

Steve Parker, M.D.