What About the Ketogenic Diet?

They say everything old is new again.  That is certainly true for the Ketogenic Diet. This high fat, adequate protein, extremely low carbohydrate diet, along with calorie restriction, was first developed in the 1920's at John Hopkins University to control seizures in pediatric patients.  Patients with epilepsy and seizure disorder would be admitted to the hospital for medical management of their acute seizure activity.  In the 1920's, there were few medications to control or subdue seizure activity.  Often, it became a waiting game of rest and observation.  Physicians and dietitians began to observe that once patients were admitted and were kept NPO (nothing to eat or drink to decrease risk of aspiration should another seizure occur), that the seizure activity greatly decreased or completely stopped, only to return once food intake was advanced. This phenomenon was hypothesized to be a result of the metabolic process known as ketosis and its relationship to the neurological anomalies causing the seizure.  Ketosis itself is the metabolic pathway used when fat is broken down  for energy as a result of inadequate carbohydrate intake.  However, it can be dangerous to be in ketosis for long periods of time due to potential acid-base imbalances and decreased growth in children, not to mention poor palpability and limited selection of foods; and therefore should only be initiated by a trained Neurologist and Registered Dietitian in ketogenic diets.  In the early years, kids on the ketogenic diet had difficulty (more than now) in maintaining/gaining weight and following growth parameters similar to peers of their age and gender.

My Personal Experience with Ketogenic Diets

When I worked at University Medical Center in Lubbock, I acted as the inpatient dietitian for the initiation of the Ketogenic Diet with Dr. Daniel Hurst, Pediatric Neurologist at Texas Tech Health Sciences Center.  Patients were carefully screened based on medical necessity (patients continuing to have many "breakthrough" seizures despite pharmaceutical management, experiencing developmental delays due to the side effects of the medication), anticipated compliance (parents MUST have the ability to say "NO" and mean it), and the overall  intellectual, social, and emotional ability of the family to adhere to the diet. For example, the child would not be allowed to have Halloween candy (not even one piece) or birthday cake.  For some parents, the emotional aspects of these choices were deal breakers.

The actual diet itself is very simple, but the devil is the details.  It meets the RDA for protein (but no more), a minimal amount of carbohydrate (the carbs in medications and even toothpaste must be accounted for), and the remainder of the calorie needs are met with fat.  At the strictest form, (during initiation), the patient would be kept NPO until they were positive for the appropriate amount of urine ketones (generally 2 days), on day 3 the diet would be initiated at 1/3 strength, and advanced daily until full strength.  The inpatient process generally lasted 5 days.  As the dietitian working with these children and their families, I would educate the families in addition to calculating every single calorie provided from food, medication, and yes, toothpaste.  I even personally measured (on a gram scale) and prepared each meal, as any slight deviation could cause the child to be out of ketosis and the whole hospitalization would have to be repeated, potentially costing thousands of dollars.  After successful initiation, the patient was then followed by the neurologist and the trained outpatient dietitian.   One of the most satisfying and rewarding moments that I have had professionally was observing a 3 year old little girl in which I had initiated the ketogenic diet.  When I first met her, she was extremely developmentally delayed due to her severe seizure disorder, having more that 30 seizures each day.  Between the seizures and medications, her little brain just didn't have the time to grasp the world around her, delaying her speech and gross motor development.  A year later, I saw the little girl who was now having seizures very rarely, walking and talking and had been able to greatly decrease her seizure medication regimen.  For me to date, that is one of the most amazing diet interventions that I have observed.

BUT... What about me?  I don't have a seizure disorder.. I just want to lose some weight...
As I stated before, the ketogenic diet is simple in the ratio...however, the implementation may have some downfalls, particularly if you don't have a medical reason to be so motivated (like eliminating seizures).  The diet allows very little carbohydrate.  This doesn't mean that carbohydrates are bad, it just means that they are limited on this particular diet.  The body (and taste buds) prefers carbohydrate, making it difficult for some adults to go "all in".  Let's say that someone goes on the ketogenic diet for 5 days, but then eats a slice of bread, 1/3 cup of pasta, or a serving of fruit, the biochemical pathway will revert out of ketosis, and would need to be re-initiated to obtain the result.  This process can be very taxing for the body and professionally I do not recommend "going in and out" of ketosis on a regular, planned basis.  Many individuals complain of some bothersome side effect during initiation and duration of the diet including headache, lack of energy, moodiness (usually "bad" moodiness), and discontent due to the limited selection of "allowed" foods. 

In 2009, the New England Journal of Medicine published a study by FM Sacks, "Weight Reducing Diets: Comparison of Weight Loss Diets with Different Macronutrient Compositions", which had several interesting findings. The purpose of the study was to compare 4 diets of differing macronutrient composition after 2 years.  The study had 811 participants that met the criteria for overweight or obese.  The participants were randomly assigned to a diet varying in carbohydrate, protein, and fat composition, but all diets created a 750 calorie deficit a day (regardless of the composition).  They all had to participate in 90 minutes of exercise per week as well.  Interestingly, all participants lost similar amounts of weight despite the macronutrient composition, indicating that the diet that works the best is the one your follow!  Behavior factors (attendance, contact, commitment, and engagement were more important than macronutrient metabolism as influencing weight loss.

BOTTOM LINE:

With reference to weight management, if you like breads and grains more than bacon and heavy cream, then follow a diet with a higher carbohydrate content.  The key is reducing the amount of total calories consumed and compliance to making behavior related changes.  On a health note, high fat diets have been associated with heart disease and increased cardiovascular risk.  Cardiac disease remains the number 1 killer of both men and women in the United States.

Thank you Alyssa Simpson for your question on Facebook.

Are You having a "Crappy" Day? Everything You NEVER Wanted to Know About Diarrhea

In my last post, I discussed ways to alleviate constipation.  So it only makes sense to follow up with a post on it's evil twin diarrhea, or CODE BROWN, as I like to call it.  (In hospital training, we learn that that there is a "code" for every almost every situation; CODE RED for fire, Code BLUE for respiratory arrest, etc...so it is only logical that when a patient has a massive amount of stool output, that should be a worthy of "CODE BROWN" status too-although hospitals don't really recognize that is a legitimate "code).

It seems when it comes to bowel movements, people find themselves in the "Goldilocks Phenomenon", where the bowel movement is either too hard (aka constipation) or it is too loose (aka diarrhea. 

Before looking at some of the common causes of diarrhea. it is important to review how the "Poop" factory works.  The gastrointestinal tract (GI tract) includes everything from the mouth to the anus.  Most of the food we eat (95%) is digested and absorbed by the time it leaves the small intestine.  What remains of the food once it has been digested and absorbed will continue traveling to the colon or the large intestine (these terms are used interchangeably). 

There are three important processes that occur in the large intestine:  1) the absorption of water (to help make the stool a nice, neat, brown package), 2) the absorptions of minerals and 3) the fermentation of fiber.  The colon is very specific to it's job description and really doesn't like when any other job is added.  In fact, when other constituents show up, the colon usually expresses it's unhappiness with the onset of "Code BROWN".

SO WHAT CAUSES CODE BROWN?

Diarrhea can have lots of contributing factors.  Therefore it is important to examine some of the most common culprits (when viruses or gastrointestinal illness have been ruled out).

One factor can be medications, including antibiotics. Antibiotics are useful to treat infectious diseases/conditions in the body, but also disrupt the "good" bacteria that is found in the intestines that helps to digest food and provides anti inflammatory properties. Individuals that are on prolonged antibiotic therapy (commonly seen in patients with Staphylococcal infections can be especially at risk for such issues, even allowing for opportunistic "bad" bacteria, like C. difficile to invade the intestine, resulting in the "Mother of Code Brown" situations.

Other medications that  contain sorbitol (a sugar alcohol the increases the osmolality of the intestines and causes excessive water to be shifted into the intestines) can cause diarrhea.  When possible, it helps to take medications not suspended in sorbitol.  Some sugar free gums can also provide a significant amount of sorbitol (for an avid gum chewer) and may also contribute to unwanted bowel behavior.

A contributing dietary factor to chronic diarrhea in some individuals is the sugar found in milk and milk products known as lactose.  In normal functioning GI tract, lactose is broken down by the enzyme lactase into glucose and galactose in the small intestine and then metabolized and used for energy.  Unfortunately, some people do not have the enzyme lactase (or have inadequate amounts of the enzyme) to break down lactose in the small intestine.  As mentioned earlier, the large intestine has the three major functions (absorb water, absorb minerals, and ferment fibers); note that there is nothing on the list about breaking down lactose.  When lactose reaches the large intestine, there is no system in place to digest or absorb it.  Therefore, the colon does what it can to rid itself of the lactose-it solicits as much water into the colon to flush the lactose out, causing gas, abdominal pain, and loose, watery stools.  Many times, lactose/milk intolerance is self diagnosed when adverse symptoms consistently occur after milk intake, and the food is completely avoided.  Avoidance of any food group can lead to nutrient imbalances and deficiencies.  There are many alternatives to regular lactose-containing cow's milk, such as Lactaid Milk (where the lactose is already broken down into galactose and glucose) or lactase enzymes are taken concurrently when consuming milk/milk products.

Occasionally, individuals may go from a highly refined diet to a diet that is high in fiber over a very short time, decreasing gastrointestinal transit time,  resulting in diarrhea.  Therefore, it is very important to increase fiber intake slowly in order to allow the gastrointestinal tract to adapt to the increased fiber intake.

WHAT TO DO IF THERE IS TOO MUCH NUMBER 2?

Regardless of the cause of diarrhea (including viruses and GI illness), the colon generally has something that need to "get rid of".  I imagine Ray Charles in the colon playing "Hit the Road Jack" as the bouncer swiftly escorts the offending agent out of the large intestine. 

Generally, slowing the process down with anti-motility agents only prolongs the time of gastrointestinal discomfort and a "crappy day".  Remember, there is an offending agent in colon. One of the most effective nutritional management strategies of diarrhea includes consuming more soluble forms of fiber.  I like to think of these as the types of fiber that visually absorb water.  For example, if  a bowl of cherrios and milk was left out all day (perhaps in the sink), the cherrios absorb a great deal of the milk and increase in size and reduce the fluid in the bowl.  Soluble fibers acts in a similar fashion when the colon has a high volume of watery stool.  The soluble fiber will soak up the watery stool, adding bulk to the stool, and slowing down the transit time, so that it may be excreted in a nice, neat, solid brown package.  Foods that are generally well tolerated and help resolve diarrhea, include breads, cereals, apples (not the skins), bananas, and rice.  It is also most important to drink lots of fluids when diarrhea is present to prevent and/or treat dehydration.

Have a HAPPY, not CRAPPY Day! @eatrightleslie