The ketogenic diet conundrum: friend or foe of heart health?

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100 years ago, ketogenic diets, which typically provide less than 10% of the daily energy intake as carbohydrates, first entered the realm of modern medicine with their demonstrated effectiveness in reducing or reversing pediatric seizures at the Mayo Clinic. While this remains valid today, there is a lingering concern that the necessary high fat intake when a ketogenic diet is followed long-term represents an undue risk for cardiovascular (heart) disease.

This concern has been a persistent barrier to the broader use of the ketogenic diet. In fact, a recent position statement from the American Heart Association (AHA) stated: “There is insufficient evidence to support any existing popular or fad diets such as the ketogenic diet and intermittent fasting to promote heart health.”

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Unrecognized by this AHA Review Committee and the 2020 Dietary Guidelines Advisory Committee is a substantial and highly cited body of published research demonstrating that a well-formulated ketogenic diet followed for durations ranging from months to years routinely results in marked improvements in weight and metabolic syndrome parameters, type 2 diabetes reversal, and most components of blood biomarkers that predict coronary heart disease (Athinarayanan 2020, Forsythe 2008, Hyde 2019, Bhanpuri 2018).

Opponents of therapeutic nutritional ketosis commonly cite two concerns with this dietary intervention.

First, many published human studies report poor dietary adherence and common side effects (Tay 2019, Gardner DIETFITS 2019).  While it is true that maintaining a diet that induces a physiologically healthy level of blood ketones is a significant behavioral challenge, most of the symptoms and side effects that are reported to deter long-term adherence are easily avoidable.

Second, it is not uncommon for some people to experience a rise in their blood levels of LDL (often vilified as ‘bad’ cholesterol when following a well-formulated ketogenic diet). Unfortunately, this single biomarker of heart disease risk continues to dominate mainstream medical thinking long after its basic premise has become…

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